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8,532
| 134,938
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45207+45208
|
Discharge summary
|
report+report
|
Admission Date: [**2123-7-20**] Discharge Date: [**2123-8-4**]
Service:
DISCHARGE DATE: Pending.
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old patient
with known aortic stenosis with increasing dyspnea on
exertion referred to Dr. [**Last Name (STitle) 1537**] for replacement of her aortic
valve.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Remote tobacco.
4. Known aortic stenosis.
5. Status post hysterectomy.
6. History of arm surgery.
7. Plate in left hip.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Ibuprofen 200 mg po tid.
2. Effexor XL 75 mg po bid.
3. Ecotrin 325 mg po 4x a week.
4. Lasix 30 mg po five days a week.
5. Lasix 40 mg Wednesday and Sunday.
6. Digoxin 0.125 mg po q day.
7. Lipitor 20 mg po q day.
8. Vitamin E.
9. ......... 325 mg q day.
10. Toprol XL 25 mg q day.
PREOPERATIVE LABORATORY DATA: White blood cell count 8.5,
hematocrit 43, platelet count 256. Sodium 141, potassium
4.3, chloride 99, bicarb 33, BUN 24, creatinine 1.2.
Patient was admitted to [**Hospital1 69**]
on [**2123-7-20**] for cardiac catheterization. Cardiac
catheterization showed a normal ejection fraction, 80% left
main disease, 90% ostial RCA disease, aortic valve area is
0.6 cm squared with a peak gradient of 60. It was decided
that the patient would be appropriate for cardiac surgery.
Cardiac Surgery consult was obtained. Pulmonary Medicine
consult was obtained due to patient's history of dyspnea on
exertion to evaluate for patient's operative risks.
Pulmonary function tests showed mild restrictive disease and
the Pulmonary Consult felt that there was no contraindication
for surgery.
The patient was taken to the operating room on [**2123-7-22**]
with Dr. [**Last Name (STitle) 1537**] for an AVR and CABG x3. The aortic valve was
replaced with a 21 mm pericardial [**Last Name (un) 3843**]-[**Doctor Last Name **] valve;
CABG x3: Saphenous vein graft to left anterior descending
artery, saphenous vein graft to OM, and saphenous vein graft
to right coronary artery. Please see operative note for
further details.
The patient was transferred to the Intensive Care Unit in
stable condition on Neo-Synephrine infusion for maintaining
blood pressure. Patient initially required significant
volume resuscitations, maintained adequate cardiac output,
and the patient remained intubated on the first postoperative
night. The patient was weaned and extubated for mechanical
ventilation on postoperative day one without difficulty.
Chest tubes were removed on postoperative day #2.
On postoperative day #2, the patient was started on
amiodarone infusion for PAC's for atrial fibrillation
prophylaxis. Patient began working with Physical Therapy.
Patient was kept in the Intensive Care Unit for aggressive
pulmonary toilet.
On postoperative day #5, patient had a chest x-ray which
showed pleural effusion. Patient underwent thoracentesis for
the right pleural effusion, which drained about 200 cc of
serosanguinous fluid with mild improvement in chest x-ray
appearance. The patient tolerated the procedure well.
On postoperative day #6, patient continued to have episodes
of paroxysmal atrial fibrillation. Patient was continued on
amiodarone and Lopressor. Patient's pacing wires were
removed on postoperative day #6. Patient tolerated the
procedure well. Patient continued to require pulmonary
toilet and intermittent aggressive diuresis. With aggressive
diuresis, patient developed elevated creatinine. The patient
was working with Physical Therapy.
On postoperative day #10, the patient developed rapid atrial
fibrillation that required administration of IV Lopressor for
rate control. The patient continued on the amiodarone.
On postoperative day #12, it was decided to obtain an
echocardiogram due to patient's continued volume overload,
atrial fibrillation, and rising creatinine. The
echocardiogram showed an ejection fraction of 60% and mild
left ventricular hypertrophy, 1+ mitral regurgitation, and
[**1-7**]+ tricuspid regurgitation. Trivial pericardia effusion,
no wall motion abnormality. It was decided that with
patient's continued paroxysmal atrial fibrillation, patient
should be anticoagulated. This was discussed with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], and the risks and
benefits of anticoagulation were discussed amongst the team,
and it was decided the patient would benefit with a goal INR
of 2. The patient was started on Heparin infusion.
Amiodarone was continued, and patient was given Coumadin.
On postoperative day #14, [**2123-8-5**], patient had been
prepared for discharge to rehabilitation, however, the
patient again developed an episode of rapid atrial
fibrillation, which required administration of IV Lopressor
and subsequently converted to sinus rhythm. The patient
continued on Heparin infusion, remained hemodynamically
stable. Patient is to be discharged to rehabilitation
facility in stable condition.
CONDITION ON DISCHARGE: Pulse 90 sinus rhythm, blood
pressure 110/58, on room air oxygen saturation 95%. Patient
is awake, alert, and oriented times three. Cardiovascular:
regular, rate, and rhythm, no rub and no murmur. Extremities
are warm and well perfused. Lower extremities with 1+
pitting edema. Lungs are clear to auscultation bilaterally,
decreased at the posterior bases. Abdomen is soft,
nontender, nondistended. Patient was tolerating a regular
diet, having bowel movements. The sternal incision is clean,
dry, and intact. There is no erythema or drainage. The
lower extremity vein harvest site is clean and dry with no
erythema or drainage.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po bid.
2. Effexor 75 mg po bid.
3. Lipitor 20 mg po q day.
4. Amiodarone 400 mg po q day.
5. Protonix 40 mg po q day.
6. Lopressor 25 mg po tid.
7. Lasix 20 mg po q day.
8. Potassium chloride 20 mEq po q day.
9. Aspirin 162 mg po q day.
10. Coumadin 2 mg on [**8-6**]. INR should be checked on [**8-7**]
for titration of INR of goal of 2.0.
Remainder of this discharge summary will be dictated upon
patient's discharge.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2123-8-5**] 09:54
T: [**2123-8-5**] 09:55
JOB#: [**Job Number 96603**]
Admission Date: [**2123-7-20**] Discharge [**2123-8-6**]
Date of Birth: Sex: F
Service:
ADDENDUM: The patient has remained in sinus rhythm for over
24 hours. The patient is cleared for discharge to rehab in
stable condition.
CONDITION ON DISCHARGE: Temperature max 97.2. Pulse 75 in
sinus rhythm. Blood pressure 94/58. Respiratory rate 14.
Oxygen saturation on 2 liters nasal cannula 95%. The
patient's weight today is 61 kilograms. The patient was 61
kilograms preop. Neurologically the patient is awake, alert
and oriented times three. Neurologically nonfocal.
Cardiovascular regular rate and rhythm. No rub or murmur.
Respiratory breath sounds were clear bilaterally, decreased
at the bases. No crackles. No wheezes. Gastrointestinal
positive bowel sounds, soft, nontender, nondistended. Right
lower extremity with 1+ edema. Steri-Strips are intact.
There is no erythema or drainage along the incision. The
sternal incision the Steri-Strips are intact. There is no
erythema or drainage. The sternum is stable.
Laboratory values for today are pending.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po b.i.d.
2. Effexor 75 mg po b.i.d.
3. Lipitor 20 mg po q.d.
4. Amiodarone 400 mg po q.d.
5. Protonix 40 mg po q.d.
6. Lopressor 25 mg po t.i.d.
7. K-Ciel 20 milliequivalents po q.d.
8. Lasix 20 mg po q.d.
9. Enteric coated aspirin 162 mg po q.d.
10. Lovenox 60 mg subq b.i.d. until INR greater then 2.0 and
then discontinue.
11. Coumadin 2 mg on [**8-6**] and then check a PT/INR on [**8-7**] and
adjust Coumadin dosing for an INR of 2.0.
DISCHARGE DIAGNOSES:
1. Status post AVR coronary artery bypass graft.
2. Postoperative atrial fibrillation.
3. Postoperative ATN.
The patient will be discharged to rehab in stable condition
and the patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in
two weeks. The patient is to follow up with Dr. [**Last Name (STitle) 28616**] in
two weeks. The patient is to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2123-8-6**] 09:10
T: [**2123-8-6**] 09:25
JOB#: [**Job Number 96604**]
|
[
"E878.2",
"997.1",
"424.1",
"414.01",
"427.31",
"511.9",
"997.3",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"35.21",
"37.23",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8109, 8876
|
7618, 8088
|
584, 5070
|
139, 332
|
354, 558
|
6772, 7595
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,313
| 121,028
|
29856
|
Discharge summary
|
report
|
Admission Date: [**2176-7-16**] Discharge Date: [**2176-7-20**]
Date of Birth: [**2145-5-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Need HD
Major Surgical or Invasive Procedure:
right femoral line placement
IR guided AV fistula thrombectomy x 2
History of Present Illness:
31 year old male with DM, psychiatric history, ESRD and frequent
hospital admissions presenting to the ED in the setting of
missed HD and nonfunctioning HD access. The patient has had
multiple interventions on his AVF, most recently on [**6-20**] he had
a thrombectomy performed by interventional radiology. He missed
his scheduled HD yesterday and presented to the ED for
evaluation. His AVF was found to be clotted and he left AMA
prior to labs or interventions could be performed.
His family and nephrology team searched for the patient and he
ultimately returned to the ED for intervention. Initial vitals
were: 98.3 164/83 109 18 100% RA. In the ED, BP initially rose
to 213/99 in the setting of agitation, once he calmed down, BP
[**Month (only) **] to 120s/50s. He was seen initially by psychiatry but was
agreeing to treatment, thus capacity evaluation deferred. He
was found to have an anion gap metabolic acidosis and was
started on an insulin gtt for presumed DKA. Per the renal team,
he was not treated for the hyperkalemia and he had no ECG
changes. Plan is to repeat labs on the floor. He is scheduled
with [**Month (only) **] surgery for graft revision tomorrow afternoon
with Dr. [**Last Name (STitle) 816**].
Currently: the patient is requesting food and pain medication.
He is feeling well and his only complaint is left leg pain. His
BG at arrival is 62 and the insulin gtt was discontinued pending
repeat labs.
Past Medical History:
1. Type 2 DM (diagnosed 13 years ago), managed by Dr. [**Last Name (STitle) 7537**]
[**Name (STitle) 58216**]
2. ESRD: CKD stage 5 (on hemodialysis since [**3-16**]) M/W/F
3. Diabetic retinopathy
4. Diabetic neuropathy
5. Diabetic myonecrosis ([**3-16**])
6. Chronic ulcer at right foot
7. Hypertension
8. Mood disorder, NOS--[**6-15**] inpatient psychiatric admission.
Notes indicate an escalation in erratic behavior with "mood
instability, irritability/lability."
9. Proximal tibia fracture [**6-15**]-closed reduction
10. h/o C.difficle infection
Social History:
not currently working, lives with family. Reports marijuana use,
no alcohol, denies IVDU, occasional tobacco. See extensive
psychiatric notes for additional details
Family History:
Extensive family history of DM. No family hx of CAD or
psychiatric conditions.
Physical Exam:
VS: 98.1 119/61 88 11 99% RA
Gen: well appearing, speaking in full sentences, no distress,
asking for food/drink
HEENT: PERRL, EOMI, OP clear, no lesions, MMM, facial plethora
Neck: JVP not seen
Car: Regular, III/VI SM heard best at right and left USB
Resp: [**Month (only) **] bases, symmetric, no crackles or wheezes
Abd: s/nt/nd/nabs
Ext: 2+ LLE edema, no RLE edema, palp pulses
Neuro: refused
Skin: dry, no rash
Pertinent Results:
Admission:
[**2176-7-16**] 07:40PM WBC-10.9 RBC-3.14* HGB-7.5* HCT-23.9* MCV-76*
MCH-23.9* MCHC-31.5 RDW-17.9*
[**2176-7-16**] 07:40PM NEUTS-81.1* LYMPHS-10.3* MONOS-5.3 EOS-3.1
BASOS-0.3
[**2176-7-16**] 07:40PM PLT COUNT-755*#
[**2176-7-16**] 07:40PM [**Month/Day/Year **]-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2176-7-16**] 07:40PM CALCIUM-7.7* PHOSPHATE-8.9*# MAGNESIUM-2.2
[**2176-7-16**] 08:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-300
GLUCOSE-500 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Ultrasound: No evidence of DVT of the left lower extremity.
Pathologically enlarged and vascular lymph nodes within the left
groin.
Left Knee X ray [**2176-7-18**]
There is an impacted medial tibial plateau fracture. There is
extensive
callus formation which has increased since the prior study.
Prominent amount of depression is seen which measures
approximately 1.4 cm. There remains a joint effusion.
Brief Hospital Course:
1. Anion Gap Metabolic Acidosis: chronic AGMA from his renal
failure. Started on an insulin gtt in the ED for presumed DKA
without evidence of ketones in urine or serum (serum value not
checked in ED, and negative after insulin started). AG improved
on insulin and required insulin to keep his K+ controlled so
maintained on insulin gtt. This was weaned off quickly.
2. Renal failure: presented after missed HD sessions. Evaluated
by [**Month/Day/Year **] surgery to fix his AVF, but unable to have
procedure on day of admission due to anemia and hyperkalemia.
Temporary right groin line placed on [**2176-7-17**] and he received HD.
Plan was for AVF repair on [**2176-7-18**] with [**Date Range **] surgery;
however, due to electrolyte abnormalities and anemia, this was
postponed. Instead, the patient was taken to IR for
thrombectomy on [**2176-7-19**] which failed. Thus, he was started on
alteplase gtt per IR and then taken to IR again on [**2176-7-20**].
Thrombectomy was successful, and the patient's fistula was used
at HD on [**2176-7-20**]. Temporary femoral HD line was d/c'ed after
successful use of AV fistula.
3. Psych: known to psychiatry at [**Hospital1 18**] from multiple consults
and admissions (last [**6-15**]). Was seen by psychiatry in the ED.
Continued outpatient olanzapine standing and prn: agitation.
Psychiatric and medical conditions are likely tightly linked and
both may affect his ability to make decisions. Mother is now
guardian.
--[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 71404**] [**Telephone/Fax (1) 5972**] from [**Location (un) **] [**Location (un) **]--social
worker
4. Microcytic Anemia: unclear why hematocrit dropped at
admission, no evidence of bleeding. Transfused 2 u prbc on
[**2176-7-17**] with stable Hematocrits.
5. Hyponatremia: baseline mid-130s. Corrected for glucose.
6. Thrombocytosis: renal failure and iron deficiency anemia can
cause reactive thrombocytosis. Has chronically elevated platelet
count, but this is slightly higher.
7. Hypertension: per patient does not take any
antihypertensives, BP controlled by HD. Currently stable.
8. s/p Proximal tibial fracture: repeat Xray ordered [**2176-7-18**].
Touch down weight bearing status, [**Month/Day/Year **] recommends outpatient
follow up with no additional intervention at this time. LENI
negative
.
9. Diabetes: off insulin gtt, need to restart home insulin
regimen and reschedule [**Last Name (un) **] follow up.
Medications on Admission:
Acetaminophen 325-650 mg every 6 hours as needed for pain
Atorvastatin 40 mg daily
Cinacalcet 30 mg daily
Famotidine 20 mg daily
Folate 1 mg daily
Olanzapine 5 mg [**Hospital1 **] and [**Hospital1 **]:prn
Nephrocaps
Nicotine TD
Aspirin 81 mg daily
Lantus 16 u qhs, Lispro SSI
Discharge Medications:
1. Tylenol 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO four times a day
as needed for pain.
2. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
3. Famotidine 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every 24
hours).
4. Olanzapine 5 mg Tablet, Rapid Dissolve [**Hospital1 **]: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day).
5. Olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
6. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Lantus Solostar 300 unit/3 mL Insulin Pen [**Hospital1 **]: Sixteen (16)
Units Subcutaneous at bedtime.
8. Insulin Lispro 100 unit/mL Insulin Pen [**Hospital1 **]: as per home
sliding scale Subcutaneous three times a day.
9. Nicotine 14 mg/24 hr Patch 24 hr [**Hospital1 **]: One (1) Patch 24 hr
Transdermal DAILY (Daily): as long as NOT smoking cigarettes,
should not be used together.
10. Cinacalcet 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
12. Lanthanum 750 mg Tablet, Chewable [**Hospital1 **]: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute renal failure
Chronic renal failure
Type II diabetes
Secondary:
1. Type 2 DM (diagnosed 13 years ago), managed by Dr. [**Last Name (STitle) 7537**]
[**Name (STitle) 58216**]
2. ESRD: CKD stage 5 (on hemodialysis since [**3-16**]) M/W/F
3. Diabetic retinopathy
4. Diabetic neuropathy
5. Diabetic myonecrosis ([**3-16**])
6. Chronic ulcer at right foot
7. Hypertension
8. Mood disorder, NOS--[**6-15**] inpatient psychiatric admission.
Notes indicate an escalation in erratic behavior with "mood
instability, irritability/lability."
9. Proximal tibia fracture [**6-15**]-closed reduction
10. h/o C.difficle infection
Discharge Condition:
afebrile, vital signs stable
Discharge Instructions:
You were admitted to the hospital after being admitted for acute
renal failure secondary to missing [**Month/Year (2) 2286**] treatments. You were
initially in the ICU and had a tempory line placed in your right
groin for hemodialysis. You underwent an IR guided procedure of
her AV fistula and your fistula was opened. You were followed by
the renal service as well [**Month/Year (2) **] surgery. You were evaluated
by orthopedic surgery during your stay here and are suppose to
be non-weight bearing on the left lower extremity.
.
Medication changes:
You were started on Lanthanum with meals as per your renal
doctors. You are being given a prescription for this.
.
You need to go to your regularly scheduled [**Month/Year (2) 2286**] treatments
and follow up with your doctors as directed below. You should
return to the ED if you experience chest pain, shortness of
breath, abdominal pain. It has been a pleasure taking care of
you at [**Hospital1 **].
Followup Instructions:
You should follow-up with your primary care physician [**Name Initial (PRE) 176**] 1
week of discharge. You can reach Dr. [**Last Name (STitle) 7537**] at ([**Telephone/Fax (1) 17612**] to
schedule an appointment at your convenience. You need to follow
up with orthopedic surgery on discharge. You can reach them at
([**Telephone/Fax (1) 2007**] and ask for [**Doctor Last Name **] to schedule. You should ask
to follow up within 1 month. You need to continue to follow up
with your outpatient nephrologist and attend your regularly
scheduled [**Doctor Last Name 2286**] sessions. Your [**Doctor Last Name 2286**] session is on MONDAY,
[**2176-7-22**] in the AFTERNOON. Listed below are the
appointments that you already have scheduled:
Provider: [**Name10 (NameIs) 6122**] WEST INPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2176-7-19**] 3:00
Completed by:[**2176-7-20**]
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77,502
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45944
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Discharge summary
|
report
|
Admission Date: [**2183-4-22**] Discharge Date: [**2183-5-2**]
Date of Birth: [**2120-12-7**] Sex: F
Service: MEDICINE
Allergies:
Captopril / Aspirin / Tetracycline / Erythromycin Base /
Penicillins / Motrin / Wellbutrin
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62 yo F with with a history of Stage III COPD (FEV1 27%) on
steroids and 3L oxygen, systolic CHF s/p ICD and ppm placement,
HTN, p/w shortness of breath to [**Hospital1 18**] on [**4-22**]. Please see
initial admit note for full history. She is transferred to the
ICU at this time for hypercarbia and increased work of
breathing. She was recently admitted on [**3-21**] for COPD
exacerbation for which she was treated with duonebs nebs, IV
steroids and required BiPAP and admission to the MICU. She was
discharged to rehab on a 2 week prednisone taper and instructed
to f/u with pulmonology and her PCP. [**Name10 (NameIs) **] her recent discharge
she has been able to titrate down her supplemental oxygen from
3L/min to 0.5 - 1 L/min.
.
On [**4-22**] she presented with increased shortness of breath and
lightheadedness with exertion since this morning. Patient stated
symptoms "feels like a normal COPD exacerbation". She also
complains of a productive cough that started that day, but
denied hematemesis, fevers, chills, n/v, chest pain, abdominal
pain, or leg swelling. She denies any known sick contacts but
has been residing in a rehab center since her discharge last
month. She reports she is up to date on her flu and pneumococcal
vaccines. She does admit to dietary indiscretions with increased
salt intake.
.
In ED VS were T 97.1 HR 110 BP 135/75 RR 20 SpO2 100%. She was
noted to have crackles at left lung base, but no acute process
on CXR. She had significant leukocytosis WBC 17.9. Troponin was
at baseline 0.02 and EKG showed sinus tach 108, LAD, NI, +TWI
V5-V6, <1mm V5-V6 (new from last admission). She recieved nebs
x2, levofloxacin 750 mg IV and solu-medrol 125 mg IV prior to
transfer to the medicine floor for presumed COPD exacerbation.
.
On the floor she was transitioned to oral prednisone 60 mg
daily, and treated with azithromycin and standing nebs. She was
continue on home diuretics and betablockers, with the assessment
that CHF was partially contributing the patients dyspnea, given
elevated BNP and crackles on exam.
.
At 1:30 pm today, patient felt sudden onset of worsening dyspnea
without chest pain. Patient was noted to have increased work of
breathing, with the use of ascessory muscles. She was saturating
94% on 2L but ABG showed CO2 of 60. She was given solumedrol,
nebs and lasix 80 mg IV x1, and morphine 2 mg IV.
Past Medical History:
1) COPD on 3L home O2 with multiple hospitalizations; multiple
intubations
- FEV1 27% in [**12/2171**]
2) Systolic CHF with dual chamber pacemaker and AICD
-placed [**12/2171**]
-dilated cardiomyopathy with EF = 20-25% on TTE [**2183-3-17**]
3) TB - treated in [**2168**], had RUL wedge resection
4) paroxysmal afib
5) GERD
6) Anxiety
7) HL
8) OA
9) GI bleed [**3-12**] duodenal/gastric ulcer
10) Osteoporosis
11) Vtach s/p ICD
12) DM - type 2 in setting of high dose steroids
13) HTN
14) Macrocytic anemia
15) Chronic leukocytosis
16) s/p myomectomy in [**2166**]
17) s/p C-section
18) neuropathy of bilateral hands
19) facial burns related to fire while using supplemental oxygen
Social History:
Retired LPN at [**Hospital3 **], LT care, substance abuse
facility. Before moving to [**Hospital3 **], lived at home with
daughter [**Name (NI) 97832**]. Ambulates with a walker. Occasionally needs
help with dressing, feeding. She has significant tobacco history
of 60 pack-years, and reports quiting after recent burn. History
of heavy EtOH, none since [**5-18**]. She denies use of illicit drugs.
Family History:
HTN, Dementia
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.9 BP: 107/80 P: 100 R: 20 O2: 96% 2L
General: Alert, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Quiet BS, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, mild clubbing, no cyanosis
or edema
Pertinent Results:
ADMISSION LABS:
[**2183-4-22**] 04:42PM BLOOD WBC-17.9*# RBC-3.39* Hgb-10.2* Hct-32.8*
MCV-97 MCH-30.0 MCHC-31.0 RDW-14.4 Plt Ct-361
[**2183-4-22**] 04:42PM BLOOD Neuts-94.5* Lymphs-3.9* Monos-1.1*
Eos-0.3 Baso-0.2
[**2183-4-22**] 04:42PM BLOOD Glucose-172* UreaN-19 Creat-0.7 Na-137
K-4.6 Cl-93* HCO3-35* AnGap-14
.
PERTINENT LABS:
[**2183-4-22**] 04:42PM BLOOD proBNP-4638*
[**2183-4-22**] 04:42PM BLOOD cTropnT-0.02*
[**2183-4-23**] 05:48AM BLOOD CK-MB-5 cTropnT-<0.01
[**2183-4-25**] 02:00PM BLOOD CK-MB-3 cTropnT-0.01
[**2183-4-23**] 05:48AM BLOOD CK(CPK)-60
[**2183-4-25**] 02:00PM BLOOD CK(CPK)-26*
[**2183-4-22**] 04:56PM BLOOD Lactate-2.0
[**2183-4-23**] 02:04PM BLOOD Lactate-2.3*
[**2183-4-23**] 06:16PM BLOOD Lactate-1.4
[**2183-4-25**] 09:40AM BLOOD calTIBC-345 Ferritn-46 TRF-265
[**2183-4-25**] 09:40AM BLOOD Ret Aut-2.4
.
DISCHARGE LABS:
................................................................
MICROBIOLOGY:
[**2183-4-24**] Urine Legionella Ag: negative
[**2183-4-24**] Respiratory Viral Screen/Cx: negative
[**2183-4-25**] MRSA Screen: negative
[**2183-4-26**] Stool: negative for C. diff
................................................................
IMAGING:
[**2183-4-22**] CXR: Minimal bibasilar atelectasis. COPD. No
radiographic evidence for pneumonia or congestive heart failure.
.
[**2183-4-25**] CTA:
1. No pulmonary embolism or acute pathology. No pneumonia or
pulmonary edema. Minimal bibasilar subsegmental atelectasis.
Minimal right pleural effusion.
2. Stable appearance of right upper lobe wedge resection. Severe
emphysema with upper lobe predominance. Similar severe
cardiomegaly.
3. 10 x 8 mm rounded left lower lobe nodule, increased from 7 x
7 mm on [**2183-3-14**]. The apparent growing size in a short
interval favors infectious or inflammatory in etiology, but
neoplasm remains high in the differential given the [**Hospital 228**]
medical history. A three-month followup must be performed per
recommendation from the prior study.
.
[**2183-4-28**] CXR: Previous left lower lobe atelectasis or
consolidation has improved. Lungs are severely emphysematous but
clear of any focal abnormality. There is no vascular engorgement
or appreciable pleural effusion. Heart size is top normal,
improved since the earlier examinations. Transvenous right
atrial pacer and right ventricular pacer defibrillator leads
follow their expected courses. Chain suture suggests prior wedge
resection from the right upper lobe.
Brief Hospital Course:
62 year old woman with with a history of Stage III COPD (FEV1
27%) on steroids and 3L oxygen, systolic CHF s/p ICD and
pacemaker placement, HTN, who p/w shortness of breath and was
transferred to the MICU for hypercarbia and worsening dyspnea.
.
# Hypercarbic respiratory failure: Patient admitted with
dyspnea, initially felt to be secondary to a COPD exacerbation.
She was first admitted to general medicine floor and had been
started on steroids, azithromycin, and nebs. Was transferred to
MICU on [**4-23**] (HD #1) given concern that she was tiring on the
floor and might require BiPAP. Trigger for COPD exacerbation
unclear. Respiratory viral screen negative, urine legionella
antigen negative, and no evidence of pneumonia on CXR or CT.
Patient was continued on steroid taper, azithromycin x5 days,
and albuterol/ipratropium nebs. As patient on long term
steroids, continued Bactrim for PCP [**Name Initial (PRE) **]. Patient trialed briefly
on BiPAP on several occasions in ICU, though did not tolerate
well. Serial ABGs revealed pCO2 in 60s-70s, likely close to
patient's baseline. Was also some concern for systolic CHF
exacerbation contributing to respiratory distress. Patient
endorsed dietary indiscretion and had elevated BNP, though
imaging was not suggestive of significant pulmonary edema. Given
known mod-severe MR [**First Name (Titles) **] [**Last Name (Titles) **] 20-25%, patient was diuresed with
subsequent improvement in dyspnea (see CHF discussion below).
Had CTA chest [**4-25**] which did not demonstrate PE. She was called
out from the MICU on [**2183-4-29**] and maintained O2 saturations on
nasal canula. Her home steroid dose was continued.
.
# Systolic CHF: Ms. [**Known lastname **] has a history of dilated cardiomyopathy
with EF 20-25%, as well as mod-severe MR. CXR without
overwhelming pulmonary edema on transfer to ICU, and she had
minimal hypoxia. She was continued on beta blocker, and diuresed
with lasix IV. Patient had some improvement in dyspnea with
diuresis, suggesting pulmonary edema was likely contributing to
respiratory distress as above. In setting of aggressive
diuresis, patient developed contraction alkalosis. Started on
acetazolamide [**4-26**]. Restarted torsemide [**4-26**], though dose
increased from home dose of 20mg [**Hospital1 **] to 60mg daily, and also
added valsartan for afterload reduction. In setting of adding
[**Last Name (un) **] to regimen, patient developed hypotension to 70s but was
mentating well throughout episode. Holding parameters for
antihypertensive regimen were adjusted, and patient's BP
improved with boluses of NS 250cc x2. The [**Last Name (un) **] was discontinued.
On return to the general medicine floor, the patient was
maintained on home dose of torsemide 20 mg [**Hospital1 **] with a I/O goal
of net 0. A small dose of metoprolol, 6.25mg [**Hospital1 **] was added
[**2183-4-30**] to help with tachycardia. Ms. [**Known lastname **] PCP was [**Name (NI) 653**]
regarding her history of allergy to ACEI. She had angioedema
with captopril in the [**2162**], but has tolerated irbesartan in the
past. We contemplated starting irbasartan at a miniscule dose to
decrease afterload and improve her forward cardiac output in the
setting of severe mitral regurgitation. However, in the end it
was decided that her hemodynamic status was too fragile to
antihypertensives and since she had been stable for the last
three days on the floor this medication was not started.
.
# Neuropathic pain: Continued tylenol and oxycodone prn pain.
.
# Anemia: HCT was stable in the 30s.
.
# Code Status: Full Code. Per discussion with patient and her
daughter, who is also her HCP, patient has been intubated 5
times and has been extubated successfully. Therefore, at this
time they would still want her to be intubated if medically
necessary, and daughter would decide when to withdraw care after
a few days if prognosis was poor. Palliative care was consulted
for help with a goals of care discussion after Ms. [**Known lastname **] got back
to the floor. She maintained that she would like to be full code
and continue aggressive medical therapy. She had worked with
[**Hospital 3005**] hospice in the past and graduated from her benefits.
Palliative care moderated the discussion of returning to rehab
or going home with hospice care. It was decided that the patient
would return to rehab and apply for re-enrollment in hospice
with a goal of eventually transitioning to her daughter's home.
.
# Leukocytosis: Patient with chronic leukocytosis (WBC [**11-26**]);
may be related to her steroid use or chronic inflammatory state.
This was montiored and reached a high of 15.9, but no localizing
symptoms or fevers occurred.
.
# Anemia: Given [**Hospital 228**] medical history and normal MCV she
likely has anemia of chronic disease. A daily ferrous sulfate
supplement was continued.
.
#Communication: [**First Name9 (NamePattern2) 97832**] [**Known lastname **] (daughter) [**Telephone/Fax (1) 97834**]
Medications on Admission:
1. Calcium carbonate 500 mg po bid
2. Multivitamin po daily
3. Ferrous sulfate 325 mg po daily
4. Omeprazole 40 mg po bid
5. Docusate sodium 100 mg po bid prn
6. Senna 8.6 mg po bid prn constipation
8. Torsemide 20 mg po bid
9. Acetaminophen 1 g po tid prn pain
10. Lorazepam 0.5 mg q6h prn anxiety/pain (has not received
recently)
11. KCl 20 meq po daily
12. Vitamin D3 400 mg po daily
13. Fluticasone-salmeterol 500-50 mcg/dose inh [**Hospital1 **]
15. Bactrim DS po QMonWedFri
16. Prednisone 25 mg po daily
17. Oxycodone 5 mg po q4h prn pain
19. Metoprolol 100 mg ER daily
20. Albuterol neb q4h prn
21. Spiriva with HandiHaler 18 mcg daily
22. Cetirizine 10 mg daily
Discharge Medications:
1. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
3. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety .
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
13. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed for sob, wheezing.
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
16. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
17. potassium chloride 25 mEq Packet Sig: One (1) PO once a
day.
18. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO 3 hrs as needed for
pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
COPD exacerbation
CHF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during your recent
admission for COPD exacerbation.
You were treated with steroids, nebulizer treatments, nasal
oxygen, and azithromycin. Your care required admission to the
ICU. There, you were treated with Bipap and diuretics. On
[**2183-4-29**], you were transferred back to the floor. You
maintained your oxygen saturation with nasal oxygen. Your hand
pain was controlled with home oxycodone. We held your home doses
of metoprolol and hydralazine because you had periods where your
blood pressure was too low. We then restarted the metoprolol at
a lower dose, 6.25mg [**Hospital1 **].
You need to continue omeprazole, bactrim, calcium and vitamin D
because you take steroids daily.
In summary,
We decreased your metoprolol to 6.25mg [**Hospital1 **].
Followup Instructions:
Please follow-up with your primary care physician. [**Name10 (NameIs) **] should
discuss being referred to a pulmonologist with her.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] N.
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]
****Please discuss with the staff at the facility a follow up
appointment with your PCP in the next 1 to 2 weeks or when you
are ready for discharge****
Name: [**Last Name (LF) 9303**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appt: We are working on an appt for you in the next month. The
office will call you at home with an appt. If you dont hear
from them by Monday afternoon, please call them directly with an
appt.
|
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|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14246, 14316
|
6917, 11906
|
358, 364
|
14382, 14382
|
4436, 4436
|
15411, 16384
|
3888, 3904
|
12626, 14223
|
14337, 14361
|
11932, 12603
|
14558, 15388
|
5290, 6894
|
3919, 4417
|
311, 320
|
392, 2749
|
4452, 4753
|
14397, 14534
|
4769, 5274
|
2771, 3454
|
3470, 3872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,362
| 198,738
|
33158
|
Discharge summary
|
report
|
Admission Date: [**2179-8-25**] Discharge Date: [**2179-8-27**]
Date of Birth: [**2158-5-11**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3129**]
Chief Complaint:
Headache, N/V, hypertension
Major Surgical or Invasive Procedure:
Peritoneal Dialysis
MICU stay
History of Present Illness:
HPI: Ms. [**Known lastname 76867**] is a 21 year old female with MPGN s/p renal
transplant ([**7-13**]) and recurrent MPGN with removal of
transplanted kidney on [**2179-7-7**] admitted for headache, nausea,
vomiting, and hypertension. Of note, she has been admitted
several times since [**2179**], most recently [**Date range (3) 77068**],
for hypertensive urgency/emergency and for generalized tonic
clonic seizures at the end of [**Month (only) **]. She has been on peritoneal
dialysis for several months; her HD catheter was removed last
month. The patient noted headache last night "all over" her head
which started at about 10:00 PM, which is her usual headache
associated with elevated blood pressure. She then experienced
nausea and vomiting and presented to the emergency room.
.
In the ED, initial vitals T 97.9, BP 208/138, HR 97, RR 20, 97%
on RA. She received labetalol 10 mg IV X 2 and was then placed
on a labetalol gtt. She also received dilaudid 1 mg IV X 2 and
zofran 4 mg IV X 1 for nausea. Throughout her ED course, her BP
ranged from 180s-190s/120s-130s. Her HR ranged in the 90s-100s.
Her temperature increased to 99.3.
.
On arrival to the ICU, the patient states her headache is [**5-18**]
compared with 10/10 at its worst. She reports ongoing nausea but
no vomiting currently. She reports no other symptoms, including
no abdominal pain or diarrhea. She reports taking her
medications as prescribed (PM doses taken at 8:00 pm) and
performing her PD without difficulty each night.
.
ROS: No fevers, chills, or sweats. No sore throat, nasal
congestion, or difficulty swallowing. Vomiting but no
hematemesis. No chest pain or difficulty breathing. No abdominal
pain or pain at site of PD catheter
Past Medical History:
Past Medical History:
* MPGN: Diagnosed age 9 by biopsy. S/p LRRT in 08/[**2175**]. Post
transplant pt was doing well, but had rising Cr for two years.
In
[**6-/2178**] pt presented with uncontrolled BP requiring ICU
admission for Isradipine drip. Repeat biopsy showed a type 1
MPGN. Negative Hep C, Hep B, [**Doctor First Name **], and renal U/S from NMEC showed
stable AVF. Her creatinine peaked to 4's and she was started on
steroids, prograf and cellcept. In [**1-/2179**], she required 3
sessions of HD through a right upper chest catheter. Creatinine
slowly recovered to 3.2. Plasmapheresis was then initiated with
plan to then treat with Rituximab. She only underwent 3 sessions
of pheresis. Outpatient neprhologist Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] & Dr.
[**Last Name (STitle) 118**]. S/p nephrectomy of transplanted kidney on [**2179-7-7**] per
Dr. [**First Name (STitle) **].
* Peripheral edema and abdominal striae [**1-9**] steroids
* HTN [**1-9**] steroids and renal disease, multiple admissions for
hypertensive emergency.
* Hemolytic Anemia - previously seen by heme/onc who felt it was
[**1-9**] to malignant hypertension
* Migraines
Social History:
Social History: Denies ETOH, illicit drugs, tobacco.
Family History:
Family History: No history of kidney disease, malignancy, heart
disease, or diabetes.
Physical Exam:
Physical Exam:
VS: T 98.7 BP 199/136 P 91 R 17 O2 98% RA
GEN: drowsy but arousable, answering questions appropriately, no
acute distress
HEENT: pupils equal and reactive bilaterally, EOMI, sclerae
injected bilaterally but anicteric, MM slightly dry, tongue
midline with symmetric palate elevation, OP clear
RESP: clear to auscultation bilaterally
CV: RRR, loud 3/6 systolic murmur heard throughout the
precordium
ABD: soft, PD catheter in LLQ, normoactive bowel sounds,
nontender to palpation throughout
EXT: no peripheral edema, DP pulses 2+ bilaterally
SKIN: diffuse excoriations but no focal rash
NEURO: alert, appropriate, oriented X 3, CN II-XII intact,
moving all extremities with 5/5 strength in hand grip, intrinsic
hand muscles, biceps, triceps, shoulder shrug, hip flexion,
ankle dorsiflexion and plantarflexion; sensation intact to light
touch bilateral upper and lower extremities; no clonus, toes
equivocal bilaterally
Pertinent Results:
[**2179-8-25**] 02:00PM OTHER BODY FLUID WBC-10* RBC-28* POLYS-10*
LYMPHS-37* MONOS-46* EOS-7*
[**2179-8-25**] 09:21AM GLUCOSE-118* UREA N-69* CREAT-11.8*
SODIUM-138 POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-23 ANION GAP-24*
[**2179-8-25**] 09:21AM CK(CPK)-21*
[**2179-8-25**] 09:21AM CK-MB-NotDone cTropnT-0.04*
[**2179-8-25**] 09:21AM CALCIUM-10.0 PHOSPHATE-11.1* MAGNESIUM-2.1
[**2179-8-25**] 09:21AM WBC-7.8 RBC-3.89* HGB-12.2 HCT-36.6 MCV-94
MCH-31.3 MCHC-33.3 RDW-17.1*
[**2179-8-25**] 09:21AM PLT COUNT-290
[**2179-8-25**] 09:21AM PT-12.6 PTT-24.9 INR(PT)-1.1
[**2179-8-25**] 01:45AM GLUCOSE-126* UREA N-71* CREAT-11.2*
SODIUM-139 POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-24 ANION GAP-25*
[**2179-8-25**] 01:45AM estGFR-Using this
[**2179-8-25**] 01:45AM ALT(SGPT)-18 AST(SGOT)-18 LD(LDH)-321* ALK
PHOS-68 AMYLASE-194* TOT BILI-0.1
[**2179-8-25**] 01:45AM LIPASE-74*
[**2179-8-25**] 01:45AM ALBUMIN-4.1 CALCIUM-10.7* PHOSPHATE-11.6*
MAGNESIUM-2.3
[**2179-8-25**] 01:45AM WBC-7.7 RBC-3.83* HGB-11.8* HCT-35.9* MCV-94
MCH-30.7 MCHC-32.7 RDW-17.3*
[**2179-8-25**] 01:45AM WBC-7.7 RBC-3.83* HGB-11.8* HCT-35.9* MCV-94
MCH-30.7 MCHC-32.7 RDW-17.3*
[**2179-8-25**] 01:45AM NEUTS-74.7* LYMPHS-9.7* MONOS-4.0 EOS-10.7*
BASOS-0.7
[**2179-8-25**] 01:45AM PLT COUNT-307
********************Studies****************
CT HEAD W/O CONTRAST Study Date of [**2179-8-25**] 1:38 AM
FINDINGS: There is no intra- or extra-axial hemorrhage, edema,
mass effect, shift of normally midline structures, or acute
major vascular territorial infarction. The ventricles and sulci
are normal in size and configuration. There is mild mucosal
thickening with mucus-retention cysts in both maxillary sinuses.
Osseous structures are unremarkable.
IMPRESSION: No acute intracranial process.
CHEST (PA & LAT) Study Date of [**2179-8-25**] 1:52 AM
Heart is moderately enlarged. Otherwise,
cardiomediastinal and hilar contours are normal. The lungs are
clear without consolidation or pulmonary edema. There is no
pleural effusion or
pneumothorax. Osseous structures are normal.
IMPRESSION: Cardiomegaly, without an acute cardiopulmonary
process.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 76867**] is a 21 yo F with history of ESRD on PD s/p
failed renal tx after recurrence of MPGN, with recurrent
admissions for hypertensive urgency, admitted again with
hypertensive urgency. [**Known firstname **] required MICU care to manage her
symptomatic hypertension via IV drugs as she could not keep down
PO meds.
In the MICU, [**Known firstname 76880**] hypertensive urgency was managed by
Labetalol and Nicardipine gtt. Once her headache and nausea
improved on this regimen, she was transitioned to PO home meds
overnight prior to transfer to the floor. Her home dose
hydralazine was increased from 50mg to 100mg PO TID.
Her other symptoms including HA and nausea were treated with
Zofran and Percocet respectively. She did not have any signs of
adverse rxn to Percocet during this hospitalization. [**Known firstname **]
was also started on Divalproex for here Migraine HAs. She
achieved near complete resolution of these symptoms once her
blood pressure was back under good control, and on the morning
of discharge she was much improved compared to her original
presentation.
In regards to her other medical issues, [**Known firstname **] was seen by the
renal transplant team and her PD schedule was maintained while
she was inpatient. Also, she was noted to have an eosinophilia
during this admission that was not pursued further than
differentials to follow the trend. She has been worked up and
treated with steroids for this in the past, and may need repeat
evaluation +/- treatment.
At the time of discharge arrangements were made for [**Known firstname **] to
f/u with her primary care nephrologist as well as the [**Hospital **] clinic.
[**Known firstname **] remained full code throughout this hospitalization.
Medications on Admission:
1. Sevelamer HCl 800 mg PO TID W/MEALS
2. B Complex-Vitamin C-Folic Acid 1 mg PO DAILY (Daily)
3. Clonidine 0.1 mg PO TID (3 times a day)
4. Lisinopril 40 mg PO DAILY
5. Losartan 100 mg PO BID
6. Hydralazine 50 mg PO TID (3 times a day)
7. Aluminum Hydroxide Suspension (30) ML PO TID W/MEALS
8. Metoprolol Tartrate 150 mg PO BID
9. Isradipine 15 mgPO TID
10. ZOFRAN ODT 4 mg PO very 6-8 hours as needed: for
nausea/vomiting. Place under-tounge and allow to dissolve.
11. Percocet 2.5-325 mg PO every six (6) hours as needed for
pain
Discharge Medications:
1. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Thirty
(30) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
7. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
8. Isradipine 5 mg Capsule Sig: Three (3) Capsule PO q8hours ().
9. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
10. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day for 6 days:
take from [**8-27**] to [**2179-9-1**].
11. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day: start on [**9-2**]
and continue on this medication indefinitely for migraine
prevention.
12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
13. Motrin 800 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for headache.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Hypertensive emergency
2. End Stage Renal Disease
3. Migraine
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with very elevated blood pressures and a
headache. You were briefly in the intensive care unit as you
needed a continuous IV medication to bring your blood pressure
down. Your migraine was treated with medications. Your
peritoneal dialysis was continued.
Please keep all your medical appointments.
Please continue all your medications as prescribed, but with the
following changes:
1. Your hydralazine has been increased to 100 mg three times
daily
2. Please take depakote 125 mg daily for 6 more days. Then
increase depakote 125 mg twice daily from then on. Take
Depakote regardless if you have a headache or not.
3. Please take Excedrin Migraine or Motrin when you feel the
onset of a migraine.
4. Your Sevelamer has been increased to 1600 mg three times a
day with meals.
If you have any of the following symptoms, please call your
doctor or go to the nearest ED: fever>101, chest pain, abdominal
pain, worst headache of your life, sudden vision changes, or any
other concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2179-12-6**] 1:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
KS [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
[**9-13**] at 9:00 AM
Please keep your Peritoneal [**Hospital **] Clinic appointment on
[**Last Name (LF) 766**], [**8-30**] at [**Hospital 24442**] Hospital.
Completed by:[**2179-9-15**]
|
[
"787.01",
"288.3",
"583.1",
"585.6",
"V42.0",
"283.9",
"403.01",
"345.10",
"346.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10290, 10296
|
6577, 8361
|
296, 327
|
10424, 10434
|
4412, 6554
|
11499, 12062
|
3372, 3444
|
8946, 10267
|
10317, 10317
|
8387, 8923
|
10458, 11476
|
3474, 4393
|
229, 258
|
355, 2074
|
10336, 10403
|
2118, 3269
|
3301, 3339
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,295
| 109,250
|
44733
|
Discharge summary
|
report
|
Admission Date: [**2160-4-17**] Discharge Date: [**2160-4-19**]
Date of Birth: [**2100-6-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
AMS, hypoglycemia
Major Surgical or Invasive Procedure:
extubated here (intubated at OSH)
History of Present Illness:
59 yo man with IDDM, EtOH cirrhosis transferred from
[**Hospital1 **] ED here for management of AMS. Per EMS notes,
family reported pt became agitated and went into room. They went
to check on him and found him unresponsive with cyanotic head,
neck, and face. When EMS arrived, FSG was 29. Pt was placed on
15L O2. Pulse was not appreciated and pt thought to have agonal
breathing, so CPR was done for "PEA arrest" while IV fluids
started. After a minute of CPR, pulse was found. Pt given 1 amp
D50 with repeat FSG 145 and improved MS. EKG was NSR @ 70 bpm.
He was brought to the [**Hospital1 **] ED where FSG was 158. He
was reportedly conversant on arrival and following commands but
thought to have "agonal breathing" so was intubated. EKG read as
junctional rhythm. CT head negative for acute intracranial
changes. The pt was transferred here for further management.
.
In the ED, initial VS were: Afebrile, P 75, 143/69 RR 20, O2sat
100% on PS, FSG 105. Intubated but awake & following commands.
2->1 pupils. BS ok. 1+ b/l pitting edema. EKG without ischemic
changes, prolonged PR. CXR showed ETT in good position. Ammonia
pending. VS on transfer: T 98.3, P 92, BP 119/71, RR 20, O2sat
100% on PS 10/5, FiO2 40%.
.
On the floor, pt has been extubated. Complains only of sore
throat [**2-5**] intubation. He cannot recall the evening's events but
recalls being in his USOH prior. He has had widely fluctuant FSG
recently with AM FSG as low as 40s; this AM was in 70s and
asymptomatic. He reports normal meals; no N/V/D; no
F/C/CP/cough/SOB/dysuria. He was admitted to [**Location (un) 1459**] [**Hospital1 107**]
1 month ago for similar episode of AMS in the setting of
hypoglycemia and presumed hepatic encephalopathy.
.
Review of systems:
As above, otherwise negative.
Past Medical History:
Hypertension
Hyperlipidemia
Type 2 DM c/b nephropathy and diabetic neuropathy
EtOH cirrhosis without varices on [**11-10**] EGD
Anemia thought due to EtOH BM suppression per pt
OSA
Obesity
B/l knee osteoarthritis
S/p left knee meniscus repair in [**2152**]
S/p bilateral cataract surgery
Social History:
Does computer sales from home. Lives with wife and mother. [**Name (NI) **]
1 son and 1 daughter.
- Tobacco: Denies
- Alcohol: H/o [**1-7**] scotch on weekends x 25 years, then [**1-7**]
scotch daily x 1 year until [**4-11**], abstinent since.
- Illicits: Denies.
Family History:
Father with alcoholic cirrhosis, died of "thoracic aneurysm."
Uncle with diabetes.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: +Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema at ankles b/l
Neuro: AAO x 3, CN II-XII intact, strength 5/5, sensation to LT
intact, cerebellar fxn nl, no pronator drift, +mild tremor,
reflexes symmetric, toes downgoing on Babinski, gait not
assessed.
Pertinent Results:
[**2160-4-18**] 03:49AM BLOOD WBC-8.3# RBC-4.50* Hgb-12.9* Hct-38.3*
MCV-85 MCH-28.8 MCHC-33.8 RDW-17.6* Plt Ct-97*
[**2160-4-18**] 03:49AM BLOOD Neuts-80.4* Lymphs-10.6* Monos-7.9
Eos-0.6 Baso-0.5
[**2160-4-18**] 03:49AM BLOOD Plt Ct-97*
[**2160-4-18**] 03:49AM BLOOD PT-14.8* PTT-32.3 INR(PT)-1.3*
[**2160-4-18**] 12:45AM BLOOD Glucose-93 UreaN-29* Creat-1.9*# Na-144
K-4.2 Cl-110* HCO3-22 AnGap-16
[**2160-4-18**] 12:45AM BLOOD ALT-35 AST-82* AlkPhos-83 TotBili-1.4
[**2160-4-18**] 03:49AM BLOOD CK(CPK)-432*
[**2160-4-18**] 03:47PM BLOOD CK(CPK)-301
[**2160-4-18**] 03:49AM BLOOD CK-MB-10 MB Indx-2.3 cTropnT-0.07*
[**2160-4-18**] 03:47PM BLOOD CK-MB-6 cTropnT-0.05*
[**2160-4-19**] 07:35AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
[**2160-4-18**] 12:15AM BLOOD Ammonia-65*
[**2160-4-18**] 12:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
cxr [**4-17**]: IMPRESSION:
1. Adequate endotracheal tube position.
2. Cardiomegaly, with central vascular congestion suggesting
volume
overload/decompensation.
Brief Hospital Course:
59 yo man with h/o IDDM, alcoholic cirrhosis p/w AMS, found to
be hypoglycemic with report of PEA arrest and intubation for
airway protection admitted to the medical ICU for further
management.
.
# Hypoglycemia: He has a history of labile blood sugars and was
found to be symptomatically hypoglycemic requiring EMS. During
his hospitalization his sugars were closely monitored. [**Last Name (un) **]
diabetes service was consulted regarding insulin management. He
was restarted on a reduced dose of levemir and a modified
insulin sliding scale as well as symlin.
-Pt asked to make f/u with his endocrinologist asap
.
# Altered mental status: He was found to be confused in the
setting of hypoglycemia that rapidly corrected with return to
normoglycemia. CT head at the outside hospital was negative for
intracranial bleed. At [**Hospital1 18**], the patient was at baseline mental
status with a non-focal neurological exam.
.
# Questionable PEA arrest: Pt returned to hemodynamic stability
with less than one minute of chest compressions in the field.
Given his low blood sugar in the field and the rapidity with
which he recovered, it is not clear that he had a true cardiac
arrest. He had EKGs from OSH which showed a junctional rhythm
with occasional PACs. At [**Hospital1 18**], pt was in NSR. He was monitored
on telemetry without event. Pt was also intubated in the field,
extubated on admission to [**Hospital1 18**].
# Chronic renal failure: He was found to have an elevated
creatinine of 1.9, with recent baseline of 1.7. Medications
were renally dosed. Nephrotoxic medications were held. Pt
already had f/u arranged with his nephrologist for 3days
post-discharge.
.
# Anemia: Pt reports seeing hematologist for chronic anemia,
presumed BM suppression [**2-5**] EtOH (hct ~35). Continued iron,
folic acid, MVI.
.
# Thrombocytopenia: This was thought likely to be due to alcohol
or cirrhosis. No e/o active bleeding and similar to prior
measurements.
.
# Cirrhosis: Does not appear acutely decompensated at this time.
Continued nadolol and lactulose.
.
# Hypertension: Blood pressures ranged from 100s to 140s
systolic while he was continued on home dose of lisinopril,
lasix, and nadolol.
.
# Hyperlipidemia: He was continued on home dose of Zetia.
.
# COPD: He was continued on his home regimen of advair and
albuterol/ipratropium nebs as needed.
Medications on Admission:
Albuterol prn
Nadolol 20mg daily (per pt, no longer on atenolol)
Bupropion SR 150mg daily
Ergocalciferol [**Numeric Identifier 1871**] units qmonth
Ezetimibe 10mg daily
Fluticasone-Salmeterol
Folic acid 1mg daily
Furosemide 20mg daily
Levemir 30 units qAM, 35 units qhs
Apidra sliding scale
Lisinopril 10mg daily
Morphine SR 15mg q12h ?
Oxycodone 5-10mg q4h prn pain ?
MVI
Pramlintide (Symlin) 120 mcg 3 times daily before each meal
(dose?)
Topiramate 150mg [**Hospital1 **]
Tramadol 50mg qid prn pain
Iron 325mg daily
Pyridoxine SR 400mg daily
Lactulose 2 tsp tid w/ meals
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q2H (every 2 hours) as needed for
sob/wheezing.
2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
4. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a month.
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Levemir 100 unit/mL Solution Sig: Twenty (20) UNITS
Subcutaneous at bedtime.
10. Apidra 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous four times a day.
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Symlin 600 mcg/mL Solution Subcutaneous
13. Topiramate 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
14. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Pyridoxine 50 mg Tablet Sig: Eight (8) Tablet PO DAILY
(Daily).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for titrate to 3 BM daily.
17. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
primary: hypoglycemia, cardiac arrest
secondary: diabetes mellitus type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for low blood sugar and a cardiac arrest
believed to be because of the low blood sugar. You were feeling
better by the time you got here. We lowered your diabetes
medicines while you were here to prevent low blood sugar in the
future.
When you go home please take your medicines with the following
changes:
1. please DECREASE your apidra sliding scale to the one that we
give you here
2. please DECREASE your levemir to 20 units at night (and none
in the morning)
3. please restart your symlin
Followup Instructions:
Please go to the following appointments:
Name: [**Last Name (LF) 3050**],[**First Name3 (LF) **] S.
Location: [**Hospital6 17557**]
Address: [**Apartment Address(1) 17558**], [**Location (un) **],[**Numeric Identifier 17559**]
Phone: [**Telephone/Fax (1) 15916**]
Appointment: [**2160-4-28**] 11:15am
Department: ADULT SPECIALTIES
When: MONDAY [**2160-6-16**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 17785**], MD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ADULT SPECIALTIES
When: FRIDAY [**2160-6-20**] at 10:00 AM
With: [**Name6 (MD) 8741**] [**Last Name (NamePattern4) 95699**], MD [**Telephone/Fax (1) 8645**]
Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: LIVER CENTER
When: THURSDAY [**2160-8-28**] at 10:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please go to the [**Last Name (un) **] appointment that you already had
scheduled on Tuesday and please also arrange to see your
endocrinologist as soon as possible!!
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2160-4-21**]
|
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icd9cm
|
[
[
[]
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] |
[
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icd9pcs
|
[
[
[]
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|
4626, 5255
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332, 368
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9262, 9262
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3571, 4603
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2880, 3552
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2140, 2172
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275, 294
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396, 2121
|
9277, 9389
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2194, 2483
|
2499, 2765
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,794
| 172,696
|
51026
|
Discharge summary
|
report
|
Admission Date: [**2117-4-12**] Discharge Date: [**2117-4-16**]
Date of Birth: [**2048-1-7**] Sex: M
Service: MICU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 106001**] is a 68-year-old
African-American male with a history of coronary artery
disease, congestive heart failure, cerebrovascular accident,
peripheral vascular disease, and Parkinson disease who was
admitted with abdominal pain.
The patient apparently complained of one day of diffuse
abdominal pain and tightness upon presentation to the
Emergency Room. He denied nausea, vomiting, diarrhea,
constipation, and fever. In the Emergency Room, the patient
had an abdominal CAT scan which showed thrombosis of the left
renal artery and necrosis of a large portion of his left
kidney. There was also a filling defect in the superior
mesenteric artery and concern for mesenteric ischemia.
REVIEW OF SYSTEMS: Review of systems on admission was
negative for chest pain, shortness of breath, sputum
production, night sweats, cough, visual changes, dysuria,
headache, neck stiffness, and new motor symptoms.
PAST MEDICAL HISTORY:
1. Parkinson disease.
2. Status post cerebrovascular accident with resulting
right-sided weakness, dysphagia, and left arm and leg
clumsiness.
3. Hypertension.
4. Peripheral vascular disease.
5. Coronary artery disease, status post coronary artery
bypass graft in [**2114**].
6. Congestive heart failure with an ejection fraction
of 25%.
7. Insulin-dependent diabetes mellitus.
8. Pulmonary hypertension.
MEDICATIONS ON ADMISSION: (The patient's medications on
admission were as follows)
1. Aspirin 325 mg p.o. q.d.
2. Atenolol 150 mg p.o. q.d.
3. Lipitor 40 mg p.o. q.d.
4. Ibuprofen p.o. p.r.n.
5. Imdur.
6. Lasix 40 mg p.o. b.i.d.
7. Univasc.
8. Aggrenox.
9. NPH insulin 28 units q.a.m. and 14 units q.h.s.
10. Regular insulin 4 units q.a.m. and 6 units q.h.s.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient has a positive smoking history
of three packs per day for approximately 35 years. He lives
alone with family nearby and is retired.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
at the time of presentation revealed the patient had a
temperature of 97.2, a blood pressure of 219/122, a heart
rate of 80, a respiratory rate of 18, and an oxygen
saturation of 95% on an unknown amount of oxygen. He was a
pleasant gentleman in no apparent distress. Alert and
oriented to person, place, and time. Head and neck
examination showed pupils were equal, round, and reactive to
light and accommodation. Extraocular movements were intact.
The oropharynx was clear. His neck showed a jugular venous
pressure of less than 10. His lungs had crackles at the
bases. Heart was regular in rate and rhythm with a positive
fourth heart sound. The abdomen was mildly firm, diffusely
tenderness to palpation, positive bowel sounds. Back
revealed there was no costovertebral angle tenderness.
Extremities revealed no edema. Neurologic examination
revealed cranial nerves II through XII were intact. The
patient's strength was [**3-21**] in the upper and lower
extremities, and his reflexes were 2+ bilaterally.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories at
the time of admission revealed the patient had a white blood
cell count of 6.6, a hematocrit of 51.2, and platelets
of 224. His differential showed 48 polys and 43 lymphocytes.
Chem-7 showed a sodium of 140, potassium of 3.8, chloride
of 103, bicarbonate of 20, blood urea nitrogen of 17,
creatinine of 1.4. The patient had an arterial blood gas in
the Emergency Room which was 7.39/30/36 with a lactate
of 6.6. The patient had a PT of 14.8, a PTT of 30.7, and an
INR of 1.5.
RADIOLOGY/IMAGING: Electrocardiogram showed a leftward axis
with intraventricular conduction delay, left atrial
enlargement, and a left bundloid appearance, left ventricular
hypertrophy; there were no significant changes as compared
with old study.
On abdominal CT, there was occlusion of the left renal artery
with necrosis of the left kidney which appeared swollen and
acute. There was a filling defect in the superior mesenteric
artery which refilled distally.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit and heparinized for his left artery and
probable superior mesenteric artery clot. He remained
hemodynamically stable the first night, and his lactate had
decreased from 6.6 to 5 by the morning on hospital day two.
However, on hospital day two his white blood cell count
increased from 6 to 20 with a high number of bands. His
creatinine increased from 1.4 to 2.2, and his abdominal pain
worsened significantly.
The patient was evaluated by Urology, Vascular Surgery, and
General Surgery who all felt that the patient needed an
emergent abdominal angiogram to assess the extent of his
superior mesenteric artery clot and mesenteric ischemia.
This angiogram was performed on hospital day two and showed
severe atherosclerotic disease throughout the aorta, iliac,
and femoral vessels. The celiac and splenic arteries were
patent. There was a clot in the midportion of the superior
mesenteric artery with filling of some small peripheral
vessels. T-PA and papaverine were instilled into the
superior mesenteric artery with some clearance of clot and
vasodilation. The left renal artery was completely
obstructed.
Based on these findings, surgery was offered to the patient
and family by Dr. [**Last Name (STitle) 519**] of General Surgery. After hearing
Dr.[**Name (NI) 1745**] description of the extensive surgery and multiple
ostomies that would likely be necessary to remove necrotic
bowel, the patient and his family refused surgical
intervention.
The patient remained hemodynamically stable overnight on
hospital day two and throughout the day on hospital day
three. He underwent a magnetic resonance imaging, magnetic
resonance angiography of the head on hospital day three for
evaluation of a new left third nerve palsy since
presentation.
On this magnetic resonance imaging, the patient was noted to
have an incidental finding of a aneurysm in the trifurcation
of the middle cerebral artery. Given that the patient's
likelihood of survival without surgery for his mesenteric
ischemia was quite low, no intervention was undertaken for
this aneurysm.
Late on hospital day three, the patient began to have
progressive hypoxia and hypotension with blood pressures in
the 70s/40s. As the patient and his family had decided to
forego surgery, and in doing so fully understood that this
would mean the patient's likely death, no intervention was
undertaken.
The patient was made do not resuscitate/do not intubate by
his family after discussion with physicians. However, on
hospital day four, the family decided that they would like
medical treatment for his hypotension. The patient was
started on a Levophed drip.
On the morning on hospital day five, the patient's
respiratory status declined precipitously with saturations in
the middle 80s on 100% nonrebreather. The patient began to
have runs of significant tachycardia to the 190s and runs of
ventricular tachycardia lasting 20 to 30 beats. Given the
futility of pressors for treatment of mesenteric ischemia
without surgical intervention, and the patient's worsening
arrhythmias, the Levophed was stopped on the morning on
hospital day five.
The patient's pressure slowly declined, although he remained
comfortable on a morphine drip and he eventually died on
[**2117-4-16**] at 10:30 a.m.
DISCHARGE DIAGNOSES:
1. Mesenteric ischemia.
2. Left renal artery stenosis and left kidney necrosis.
3. Congestive heart failure.
4. Left third nerve palsy.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3851**]
Dictated By:[**Name8 (MD) 30425**]
MEDQUIST36
D: [**2117-4-16**] 11:55
T: [**2117-4-17**] 04:02
JOB#: [**Job Number 41596**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
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] |
7584, 7985
|
1556, 1963
|
4234, 7563
|
896, 1093
|
161, 875
|
1115, 1529
|
1980, 4215
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,701
| 109,485
|
24179
|
Discharge summary
|
report
|
Admission Date: [**2139-4-1**] Discharge Date: [**2139-4-20**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
Hypoxia, hypotension
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
[**Age over 90 **]F PMH COPD, diastolic CHF, admission for ORIF of left femur fx
complicated by LLE DVT [**5-/2138**], brought in by ambulance f/NH for
hypoxia and hypotension. Labs at NH showed leukocytosis 22k, cr
1.3, inr 6.7. DFA+ at rehab, started tamiflu, ctx, levoflox,
transferred to [**Hospital1 18**].
In [**Hospital1 18**] ED, vs 97.7, 131, 88/46, 100%NRB. Noted to have
systolics to the 70s, improved to 90s with 2L NS, initiated on
levophed gtt, then transitioned to off. EKG showed afib-rvr.
Vancomycin and cefepime initiated for HAP, given combivent nebs,
femoral line placed, given 2L NS. Cards evaluated, believes
trop 0.23 suggestive NSTEMI. Cardiology outpt attending
notified, suggested metoprolol vs amiodarone, given adenosine
6mg, then 12mg with transient slowing. SBP 90s, HR 90s.
Code status confirmed in ED to be DNR/DNI but yes to pressors
- confirmed with daughter/POA.
Past Medical History:
1. Type 2 Diabetes
2. Hypertension
3. Osteopenia
4. Nasopharyngeal cancer ([**2122**])
5. COPD
6. s/p right distal femoral fracture and right hip fracture in
[**10/2134**], no intervention
7. s/p left distal femoral fracture in [**5-/2138**] with ORIF and
subsequent LLE DVT
8. diastolic CHF (LVEF >75%) with moderate MR/TR
Social History:
currently a resident at [**Hospital 100**] Rehab and has been bedbound since
[**2134**]. She is widowed x 35 years. She smoked previously, quitting
in [**2132**]. She is a retired real estate broker. She has two
daughters - [**Name (NI) **] who resides in CT and [**Name (NI) **] who lives in
[**Location (un) 55**].
Family History:
mother died at 69 of unknown cause. Father died at 80 of unknown
cause. Two daughters in their 60's, both healthy.
Physical Exam:
Admission PE
T 97.5 BP 110/70 on levo HR 95 RR 20 99%2L
Gen - mild distress, mild resp distress with acessory muscles,
complaining of "not feeling well."
HEENT - anicteric sclera, mildly dry membranes
Heart - s1+s2+ irregular no murmurs, tachy
Lungs - decreased effort
Abdomen - distended, obese
Extremities - +edema, r fem line with bandage and oozing
.
Discharge PE
PE - T BP HR RR 96%3L Tele- sinus rhythm w/frequent PVCs,
occasionally afib
Gen/Neuro - elderly woman with NGT in place, minimally
responsive, opens eyes and turns head to voice, moving LUE
extremity only, responds to pain, does not follow commands,
appears comfortable. R facial droop.
HEENT - anicteric sclera, MMM OP clear, no [**Doctor First Name **], NG tube in place
Heart - s1+s2+ regular, no murmurs, no JVD
Lungs - CTA anteriorly and laterally
Abdomen - soft, +BS, mildly distended, obese
Extremities - +edema/ecchymoses in upper extremities, no edema
in LEs
Pertinent Results:
ADMISSION LABS:
.
[**2139-4-1**] 12:00PM GLUCOSE-256* UREA N-52* CREAT-1.3* SODIUM-141
POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-33* ANION GAP-12
[**2139-4-1**] 12:00PM WBC-21.0*# RBC-4.08* HGB-12.4 HCT-38.2 MCV-94
MCH-30.3 MCHC-32.4 RDW-14.2
[**2139-4-1**] 12:00PM NEUTS-93.9* BANDS-0 LYMPHS-3.8* MONOS-2.0
EOS-0.1 BASOS-0.2
[**2139-4-1**] 12:00PM PT-60.3* PTT-55.3* INR(PT)-7.2*
[**2139-4-1**] 12:46PM BLOOD pO2-184* pCO2-52* pH-7.39 calTCO2-33*
Base XS-5 Comment-GREEN TOP
[**2139-4-1**] 01:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2139-4-1**] 01:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
[**2139-4-1**] 01:15PM URINE RBC-[**4-15**]* WBC-[**7-21**]* BACTERIA-MOD
YEAST-FEW EPI-0-2
[**2139-4-1**] 08:51PM CK(CPK)-108
[**2139-4-1**] 08:51PM CK-MB-14* MB INDX-13.0* cTropnT-0.34*
.
OTHER LABS
[**2139-4-5**] 04:29AM BLOOD ALT-33 AST-20 LD(LDH)-256* AlkPhos-121*
Amylase-33 TotBili-0.5
[**2139-4-11**] 06:35AM BLOOD WBC-17.4* RBC-3.59* Hgb-11.1* Hct-33.5*
MCV-93 MCH-31.0 MCHC-33.2 RDW-14.2 Plt Ct-276
[**2139-4-11**] 06:35AM BLOOD PT-13.5* PTT-37.8* INR(PT)-1.2*
[**2139-4-11**] 06:35AM BLOOD Glucose-270* UreaN-19 Creat-0.4 Na-141
K-4.3 Cl-97 HCO3-36* AnGap-12
[**2139-4-15**] 09:45AM BLOOD WBC-11.8* RBC-3.59* Hgb-11.1* Hct-34.6*
MCV-96 MCH-30.8 MCHC-32.1 RDW-14.5 Plt Ct-325
[**2139-4-16**] 06:30PM BLOOD PT-12.4 PTT-25.1 INR(PT)-1.0
[**2139-4-15**] 09:45AM BLOOD Glucose-139* UreaN-14 Creat-0.4 Na-141
K-4.6 Cl-97 HCO3-39* AnGap-10
[**2139-4-15**] 09:45AM BLOOD ALT-32 AST-44* LD(LDH)-355* AlkPhos-87
TotBili-0.4
[**2139-4-3**] 05:49AM BLOOD CK(CPK)-46
[**2139-4-2**] 04:03AM BLOOD CK(CPK)-92
[**2139-4-1**] 08:51PM BLOOD CK(CPK)-108
[**2139-4-1**] 12:00PM BLOOD CK(CPK)-86
[**2139-4-3**] 05:49AM BLOOD CK-MB-NotDone cTropnT-0.30*
[**2139-4-2**] 04:03AM BLOOD CK-MB-NotDone cTropnT-0.33*
[**2139-4-1**] 08:51PM BLOOD CK-MB-14* MB Indx-13.0* cTropnT-0.34*
[**2139-4-1**] 12:00PM BLOOD cTropnT-0.23*
[**2139-4-15**] 09:45AM BLOOD Albumin-3.1* Calcium-9.4 Phos-3.6 Mg-2.1
[**2139-4-10**] 06:50AM BLOOD Triglyc-109 HDL-46 CHOL/HD-2.2 LDLcalc-31
[**2139-4-9**] 02:29PM BLOOD %HbA1c-6.8*
[**2139-4-1**] 08:55PM BLOOD Glucose-116* Lactate-1.0 calHCO3-29
.
STUDIES
CXR [**2139-4-1**]-IMPRESSION: No acute cardiopulmonary abnormalities.
CXR [**2139-4-4**]-IMPRESSION: AP chest compared to [**4-2**] and
22: Moderate cardiomegaly is chronic, small bilateral pleural
effusions have increased, pulmonary vascular congestion in the
upper lungs persists, but there is no pulmonary edema. No
pneumothorax.
CXR [**2139-4-5**]-IMPRESSION:AP chest compared to [**4-1**] through
23: Severe cardiomegaly is longstanding. Small-to-moderate left
pleural effusion stable since [**4-4**]. Pulmonary vascular
engorgement suggests a mild-to-moderate cardiac decompensation.
Left lower lobe opacification can be
explained by atelectasis present since at least [**4-1**].
Right lung shows no evidence of pneumonia. No pneumothorax.
Nasogastric tube passes into the stomach and out of view.
CHEST (PORTABLE AP) [**2139-4-14**] 11:18 PM
1. The right upper lobe airspace disease is almost cleared
indicating either it was edema or atelectasis.
2. Persistent bilateral bibasilar atelectasis with small
coexistent pleural effusion. The homogeneous opacification in
the left lung could be attributed to patient's body habitus and
positioning during the procedure.
.
ECHO [**5-18**] - [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA mod dilated. LV wall
thicknesses nl. LV hyperdynamic (EF>75%). MV leaflets mildly
thickened. Mild to mod ([**2-11**]+) MR, mod [2+] TR. Mod pulm artery
systolic htn.
.
CT Head [**2139-4-4**] IMPRESSION: Probable large left MCA ischemia. CT
perfusion or MRI are recommended for further characterization.
.
CT Head [**2139-4-7**] (Prelim): There is now marked diffuse
hypodensity seen throughout the left MCA territory, consistent
with evolution of large left MCA territory infarct. There is no
sign of intracranial hemorrhage. There is now mild regional
sulcal effacement, as well as a small amount of mass effect on
the frontal [**Doctor Last Name 534**] of the left lateral ventricle. The ventricles
are otherwise unchanged in size and the basal cisterns are not
effaced.
IMPRESSION: Evolving large left MCA territory infarct, now with
mild regional sulcal effacement, and minimal mass effect on the
frontal [**Doctor Last Name 534**] of the left lateral ventricle
.
MICROBIOLOGY
[**2139-4-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2139-4-15**] Direct Antigen Test for Herpes Simplex Virus Types 1
& 2 Direct Antigen Test for Herpes Simplex Virus Types 1 &
2-FINAL NEG; DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER
VIRUS-FINAL NEG; VARICELLA-ZOSTER CULTURE-PENDING
TAN-[**Last Name (LF) 61435**],[**First Name3 (LF) **] K.
[**2139-4-15**] SWAB GRAM STAIN-FINAL; WOUND CULTURE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, [**Female First Name (un) **] ALBICANS,
PRESUMPTIVE IDENTIFICATION}; POTASSIUM HYDROXIDE
PREPARATION-FINAL; FUNGAL CULTURE-PRELIMINARY {[**Female First Name (un) **] ALBICANS,
PRESUMPTIVE IDENTIFICATION} TAN-[**Last Name (LF) 61435**],[**First Name3 (LF) **] K.
[**2139-4-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL NEG
[**2139-4-8**] URINE URINE CULTURE-FINAL INPATIENT NEG
[**2139-4-4**] URINE URINE CULTURE-FINAL INPATIENT NEG
[**2139-4-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT NEG
[**2139-4-2**] URINE URINE CULTURE-FINAL INPATIENT NEG
[**2139-4-1**] SWAB VIRAL CULTURE-PENDING INPATIENT NEG
[**2139-4-1**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
[**2139-4-1**] BLOOD CULTURE Blood Culture, Routine-FINAL NEG
Brief Hospital Course:
Patient is a [**Age over 90 **] year old woman with past medical history of
COPD, diastolic CHF, ORIF of left femur fracture complicated by
left lower extremity DVT in [**5-/2138**], who was brought in by
ambulance from nursing home for hypoxia and hypotension,
initially admitted to ICU for septic shock, eventually
transferred to the floors when hemodynamically stable. Hospital
course by problem:
.
# Influenza/?Pneumonia/sepsis: Patient presented from nursing
home in respiratory distress, hypotensive, initially requiring a
non-rebreather, and pressor therapy after IVF resuscitation.
CXR on admission demonstrated evidence of retrocardiac opacity.
Per report from nursing home, DFA swab sent just prior to
transfer ended up positive for influenza. The patient was
treated for influenza with 5 days of tamiflu, and was initially
on vancomycin/cefepime for pneumonia, which was converted to
levofloxacin to complete a 7 day course. As above, she was
started on pressor support on admission due to
hypotension/sepsis, also with initial lactate of 2.7, but was
quickly weaned off pressors with IVF support with good
maintenance of blood pressure. Lactate normalized. As below,
the patient was noted to be in atrial fibrillation with RVR on
admission which was thought to explain her hypotension rather
than an infectious sepsis etiology. This was managed as
described below.
.
# Acute stroke: The patient developed acute MS changes early AM
on [**4-4**], with apparent right sided neglect on exam. Code stroke
was called, a CT head (without contrast) was obtained which
demonstrated a large left MCA territory stroke, embolic.
Neurology was involved and recommended no TPA given the
patient's age and co-morbidity, and recommended no need to check
an ECHO or carotid ultrasound as it would not change management.
She was maintained on a beta blocker for blood pressure
control, with IV hydralazine PRN to keep SBP < 160. She was
also started on a statin. Neurology followed along during
hospital course and felt she likely had a poor prognosis given
her age. The patient remains non-verbal without use of right
side. A repeat CT showed evolving area of infarct but no
evidence of bleed. A family meeting was held when she was on the
general medicine floor (on [**2139-4-10**] with the neurology team,
palliative care team, and primary geriatric team to discuss
goals of care. The family is still uncertain about goals of care
but determined she would not want any invasive procedures (PICC,
TEE, MRI, frequent lab draws) at this point. They would like a
couple of weeks to observe her progress and reassess her goals
of care. She was continued on metoprolol for blood pressure
control (with prn hydralazine through the NG tube) and was given
lovenox (as opposed to coumadin) for anticoagulation to avoid
need for frequent lab draws. If the family decides to pursue a
more aggressive management, neuro made the following
recommendations: obtain TTE and duplex carotids, keep LDL<70,
check HgA1c, start coumadin and get MRI head to evaluate extent
of damage.
.
# Cardiac:
A. CHF: The patient has a history of diastolic dysfunction, and
was on losartan and metoprolol during the hospital course. In
the ICU she had had recurrent problems with episodes of
hypertension leading to desaturation/wheezing, requiring tight
blood pressure and volume status control. She received IV
hydralazine PRN, IV lasix to maintain negative fluid balance.
Losartan was discontinued due to stroke above, and her blood
pressure was managed with a goal BP 140-160, and close
monitoring of volume status. On the floors she was continued on
metoprolol with po hydralazine prn to keep blood pressure within
goal range.
.
B. Rhythm: The patient was initially in atrial fibrillation on
presentation (no history of atrial fibrillation per records),
then was in normal sinus rhythm during her early hospital
course. She went back in atrial fibrillation with rapid
ventricular response in the setting of acute stroke - at that
time, she received dig load in attempt to maintain blood
pressure, but she was not continued on dig. She was maintained
on metoprolol, low dose, and spontaneously converted back to
normal sinus rhythm within 24 hours. She was not started on
coumadin for fear of converting her large ischemic stroke into a
hemorrhagic stroke. Once the repeat Head CT came back negative
for hemorrhage there was discussion of restarting her on
coumadin but the family declined as this would require frequent
blood sticks for monitoring INR and she had very poor access.
She was started on SC lovenox instead. On the floors her rate
was well-controlled on metoprolol though for her rhythm she did
go in and out of NSR and a-fib.
.
# UTI: The patient presented as above, and the u/a in ED was
positive, though no cultures were sent at that time. Repeat u/a
after 24hrs of antibiotics was negative, and culture was
negative. She completed a 7 day course of levofloxacin.
.
#. Respiratory distress overnight on [**4-14**]: The patient triggered
for hypoxia and respiratory distress, was felt to be volume
overloaded v. aspiration and received 40mg po lasix and 25mg po
hydral. She diuresed 3 L and her O2 sat improved from requiring
6LO2 to her baseline 3L O2 requirement. She looked very
comfortable the next day w/some crackles on exam so she was
given another 40mg po lasix. She subsequently appeared euvolemic
and comfortable. She had PEG placed given risk for aspiration.
She has been on aspiration precautions. I/O should be closely
monitored.
.
Rash- The patient developed linear lesions with pustules on R
scapula with a few satelite lesions on L. Could be pustular
zoster though DFA was negative (culture pending). Derm was
consulted, she was put on zoster precautions and treated with 7
days of acyclovir 500mg 5x/day per NGT for 7 days total (started
[**2139-4-13**]), finished today [**4-20**]. Please follow up viral culture and
monitor clinically for signs of further dissemination (has had
none in house).
# History of DVT: The patient has a history of DVT in [**5-18**] in
the setting of a surgical procedure in [**5-18**]. She was on
coumadin as an outpatient, and presented supratherapeutic, so
coumadin was held. FFP was administered on the day after
admission in order to reverse coumadin to remove the femoral
line. Coumadin was not restarted initially because the patient
was status post 6 months of treatment.
.
# Diabetes mellitus II: The patient was maintained on an
insulin sliding scale. 25 units lantus qhs was added for optimal
control. This can be titrated up as necessary.
.
# Renal failure: Cr elevated at 1.3 on admission, resolved
with IVF.
.
# Access: Patient had difficult peripheral access, but
patient's family did not want PICC or central line placed, so
she currently has no IV access.
.
# FEN: Patient was initially on regular diet, then after
stroke as above, had NGT placed and subsqeuently a PEG placed.
She is receiving tube feeds. The family needs to discuss goals
of care as discussed above.
.
# Code - DNR/DNI (yes to pressors)
Medications on Admission:
1. Warfarin 1.5mg qd
2. Escitalopram 10mg qd
3. Trazodone 50mg qhs
4. Losartan 50mg qd
5. Metoprolol Tartrate 12.5mg [**Hospital1 **]
6. Pantoprazole 20mg qd
7. Aspirin 81mg qd
8. Hexavitamin qd
9. Ipratropium Bromide 0.02 q4hrs
10. Albuterol Sulfate 0.083 q4hrs
11. Senna 8.6mg [**Hospital1 **]
12 Docusate Sodium 100mg [**Hospital1 **]
13. Cyanocobalamin 1,000 mcg qmonth
14. Glipizide 10mg [**Hospital1 **]
15. ISS
16. Cholecalciferol (Vitamin D3) 400u qd
17. Calcium Carbonate 500mg tid prn
Discharge Medications:
1. Influenza Tri-Split [**2138**] Vac 45 mcg/0.5 mL Suspension [**Year (4 digits) **]:
0.5 ML Intramuscular ASDIR (AS DIRECTED).
2. Ferrous Sulfate 300 mg/5 mL Liquid [**Year (4 digits) **]: Five (5) mL PO DAILY
(Daily).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Year (4 digits) **]: 2.5 Tablets
PO DAILY (Daily).
4. Citalopram 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet [**Year (4 digits) **]: 0.5 Tablet PO DAILY
(Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable [**Year (4 digits) **]: One (1)
Tablet, Chewable PO BID (2 times a day).
7. Aspirin 325 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule [**Year (4 digits) **]: One (1) Capsule PO BID (2
times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for yeast infection.
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q4H (every 4 hours).
13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
Three (3) mL Inhalation Q4H (every 4 hours).
14. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day): Hold for HR<55, SBP<100.
15. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H
(every 6 hours).
16. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
TID (3 times a day) as needed for constipation.
17. Enoxaparin 40 mg/0.4 mL Syringe [**Hospital1 **]: Forty (40) mg
Subcutaneous DAILY (Daily).
18. Lantus 100 unit/mL Cartridge [**Hospital1 **]: Twenty Five (25) units
Subcutaneous at bedtime: MD [**First Name (Titles) **] [**Last Name (Titles) **] up as needed.
19. Insulin Regular Human 100 unit/mL Cartridge [**Last Name (Titles) **]: as directed
as directed Injection every six (6) hours:
Glucose/ Insulin
0-50 mg/dL/ 4 oz. Juice; 51-150 mg/dL/ 0 Units;
151-200 mg/dL/ 3 Units; 201-250 mg/dL/ 6 Units;
251-300 mg/dL 9 Units; 301-350 mg/dL/ 12 Units ;
351-400 mg/dL/ 15 Units ;
> 400 mg/dL Notify M.D.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary
1. Non ST elevation myocardial infarction
2. Atrial fibrillation with rapid ventricular rate, currently
rate-controlled
3. Left MCA stroke with Right-sided hemiplegia
4. Leukocytosis of unknown etiology
5. Acute bronchitis
6. Acute renal failure
7. Pustular R scapula infection, possibly zoster
Secondary:
1. Chronic diastolic congestive heart failure
2. Diabetes mellitus
Discharge Condition:
R-sided hemiparesis, awakes and moves head and eyes to voice.
Mumbles some incoherent words. Moves L arm. PEG tube for
feeding. Afebrile.
Discharge Instructions:
You were admitted to the hospital because you were hypoxic and
hypotensive. You suffered from a heart attack (NSTEMI) and
developed atrial fibrillation with rapid ventricular rate. You
were treated in the ICU because you were clinically unstable.
You were treated with metoprolol and coumadin for your atrial
fibrillation. You also completed a course of antibiotics for
pneumonia and UTI, and tamiflu for presumptive flu. During your
hospitalization you had a stroke which likely occurred when you
converted from atrial fibrillation to normal sinus rhythm.
Neurology was consulted. Your coumadin was stopped and you were
started on aspirin. Although a repeat Head CT indicated you did
not have a bleed with the stroke, you were not restarted on
coumadin because you did not have IV access and your family
decided they did not want to monitor INR in order to spare you
from needing a PICC or frequent blood draws. A family meeting
was held and your family is still unsure of whether they want to
begin a stroke work-up or stroke prevention medications. You are
receiving nutrition via a PEG tube. Your white count was
elevated but no source of infection was found. We stopped
monitoring your WBC as you remained afebrile with stable vital
signs and your family wishes to minimize blood draws. You also
developed a rash that was evaluated by dermatology and felt to
be consistent with zoster. You completed a 7 day course of
acyclovir (end date [**2139-4-20**]). Dermatology also noted a lesion
on your skin that could be consistent with SCC. Your family may
decide to pursue this further by making an appointment with the
dermatologists (see below).
.
Please continue to take medications as prescribed.
.
If the patient develops fever, chills, difficulty breathing,
hypotension, hypertension or other concerning symptoms please
call the doctor.
Followup Instructions:
Please make an appointment with PCP ([**Last Name (LF) **],[**First Name3 (LF) **] M.
[**Telephone/Fax (1) 38919**]) if the patient is discharged from rehab.
.
Please make an appointment at the [**Hospital1 18**] neurology clinic ([**Telephone/Fax (1) 8951**] if the patient's family decides to pursue more
aggressive stroke work-up and management.
.
If the family wishes to pursue evaluation of a possible SCC,
please call the dermatology clinic at [**Hospital1 18**] and make a follow up
appointment ([**Telephone/Fax (1) 8132**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
Completed by:[**2139-4-20**]
|
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"518.81",
"782.1",
"584.9",
"428.0",
"250.00",
"401.9",
"427.32",
"038.9",
"785.52",
"487.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"43.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
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|
8752, 15838
|
243, 263
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|
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19426, 21273
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183, 205
|
291, 1202
|
3017, 8729
|
1224, 1558
|
1574, 1893
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,836
| 196,151
|
12975
|
Discharge summary
|
report
|
Admission Date: [**2165-5-7**] Discharge Date: [**2165-5-26**]
Date of Birth: [**2095-9-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine Sulfate
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Hypotension/Cellulitis/Sepsis
Major Surgical or Invasive Procedure:
Bedside leg debridement and VAC Dressing.
History of Present Illness:
Mr. [**Known lastname 916**] is a 69 year old individual who is s/p CABG/mech AVR on
[**2165-3-26**] who had a complicated post-op course including
pericardial tamponade on POD#3 requiring bedside intervention
who now presents with LLE erythema and a draining wound. He was
discharged to rehab on [**2165-4-15**]. His course in rehab is
significant for diagnosis of multi-drug resistant Klebsiella UTI
on [**4-29**] and a draining LLE incision what was cultured on [**5-4**]
with gram stain revealing beta-hemolytic Staph. As per report,
the leg had been edematous and cellulitic in appearance since
his arrival in rehab. He is transferred to [**Hospital1 18**] for tachycardia
and hypotension since last night as well as oliguria/anuria for
the
past "3 days".
Past Medical History:
morbid obesity
diabetes mellitus type II
aortic stenosis
coronary artery disease
pericardial tamponade
chronic venous stasis
chronic atrial fibrillation
systolic and diastolic CHF
urinary tract infection
obstructive sleep apnea
post thyroidectomy hypothyroidism
PSH:
Aortic valve replacement(25mm St. [**Male First Name (un) 923**] mechanical), aortic root
enlargement, coronary artery bypass grafts x 4(LIMA-LAD,
SVG-Dg,SVG-OM,SVG-AM) [**2165-3-26**]
thyroidectomy
Social History:
-Tobacco history: remote Quit smoking: 30+ yrs ago
-ETOH: history of alcohol abuse, quit 7 years ago
-Illicit drugs: None
Family History:
non-contributory.
Physical Exam:
Gen: morbidly obese male, intubated, sedated, no icterus
HEENT: NC/AT, EOMI, PERRLA bilat., MMM, without cervical LAD
on my exam
Cor: RRR without m/g/r, no JVD, no bruits, audible click
Inc: c/d/i
Lungs: coarse bilat.
[**Last Name (un) **]: +BS, soft, ND, NT, no masses
Ext: LLE with edema, peau d'orange, warmth, erythema; medial
knee
wound with necrotic fat, medial LLE linear wound with necrotic
fat now debrided to fascia, fascia is viable with tracking to
medial knee wound. No bogginess on lateral aspect.
On my serial exams 3 hours apart, the erythema has receded
slightly after abx. and debridement.
Pulses: fem [**Doctor Last Name **] PT DP
R p - d tri
L p - d tri
Pertinent Results:
[**2165-5-7**] ECHO
The left ventricular cavity is mildly dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 20
%). The right ventricular cavity is dilated with depressed free
wall contractility. A bileaflet aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis
and no significant aortic regurgitation is detected in
suboptimal views. The mitral valve leaflets are mildly
thickened. There is mild functional mitral stenosis (mean
gradient 4mmHg) due to mitral annular calcification. Physiologic
mitral regurgitation is seen (within normal limits). [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade.
Compared with the prior study (images reviewed) of [**2165-4-3**],
left ventricular systolic function is now more depressed (which
may be at least partly due to tachycardia). The right ventricle
now appear dilated with free wall hypokinesis. Estimated
pulmonary artery systolic pressure is now higher. Tricuspid
regurgitation is now more preominent.
[**2165-5-7**] Lower Extremity Ultrasound
Limited study. No DVT identified in either common femoral or
superficial femoral veins bilaterally. Diffuse subcutaneous left
calf edema. A small amount of focal fluid in the left calf is
likely not amenable to percutaneous drainage.
[**2165-5-25**] 03:52AM BLOOD WBC-9.0 RBC-2.89* Hgb-7.9* Hct-25.3*
MCV-88 MCH-27.2 MCHC-31.0 RDW-17.9* Plt Ct-462*
[**2165-5-26**] 05:06AM BLOOD PT-29.9* INR(PT)-3.0*
[**2165-5-25**] 03:52AM BLOOD PT-23.4* INR(PT)-2.2*
[**2165-5-24**] 04:19AM BLOOD PT-22.0* PTT-120.7* INR(PT)-2.1*
[**2165-5-26**] 05:06AM BLOOD Glucose-94 UreaN-31* Creat-1.1 Na-133
K-5.0 Cl-94* HCO3-33* AnGap-11
[**2165-5-24**] 04:19AM BLOOD Mg-2.1
[**2165-5-7**] 5:35 pm SWAB Source: L lower leg incision.
**FINAL REPORT [**2165-5-12**]**
GRAM STAIN (Final [**2165-5-7**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
WOUND CULTURE (Final [**2165-5-11**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
BETA STREPTOCOCCUS GROUP C. MODERATE GROWTH.
BETA STREPTOCOCCI, NOT GROUP A. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2165-5-11**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Mr. [**Known lastname 916**] was admitted to the [**Hospital1 18**] on [**2165-5-7**] for further
management of his hypotension and likely sepsis. He was
intubated for cardiogenic shock. He was pancultured and
antibiotics were started. The vascular surgery service was
consulted for evaluation of his lower extremity cellulitis. The
wound was debrided at the bedside with drainage of infected
material. The infectios disease service was consulted and
vancomycin and meropenum were continued. Cultures were sent
which showed moderate growth of beta streptococcus. Antibiotics
were switched to penicillin G which a 6 week course was
recommended. Physical therapy worked with him daily. Fluconazole
was given for a groin fungal infection with good results. A VAC
dressing was placed in his leg. Imaging of his leg showed no
evidence of osteomyelitis. A PICC was placed for long term
antibiotics. Coumadin was continued for atrial fibrillation and
a mechanical aortic valve.
Mr. [**Known lastname 916**] continued steady progress. He did remain in the
hospital likely longer then needed due to insurance issues. He
was discharged to rehab on hospital day 20 with explicit
instructions for follow-up, antibiotic course and wound
management. He is to continue penicillin G at least through
[**2165-6-5**]. He will see Dr. [**Last Name (STitle) **] on [**2165-6-4**] and this date may
be adjusted at that time.
Medications on Admission:
Medications - Prescription
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg [**Date Range 8426**] - 1
[**Date Range 8426**](s) by mouth once a day
GLYBURIDE - (Prescribed by Other Provider) - 5 mg [**Date Range 8426**] - [**12-7**]
[**Month/Day (2) 8426**](s) by mouth twice a day
LEVOTHYROXINE - (Prescribed by Other Provider) - 75 mcg [**Month/Day (2) 8426**]
-
3 [**Month/Day (2) 8426**](s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 40 mg [**Month/Day (2) 8426**] -
[**12-7**]
[**Month/Day (2) 8426**](s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
[**Month/Day (2) 8426**] - [**12-7**] [**Month/Day (2) 8426**](s) by mouth three times a day
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg [**Month/Day (2) 8426**] - 1
[**Month/Day (2) 8426**](s) by mouth once a day
Medications - OTC
ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) -
Dosage uncertain
ASPIRIN - (Prescribed by Other Provider) - 81 mg [**Month/Day (2) 8426**],
Delayed
Release (E.C.) - 1 [**Month/Day (2) 8426**](s) by mouth once a day
CYANOCOBALAMIN [VITAMIN B-12] - (Prescribed by Other Provider)
-
Dosage uncertain
DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) -
Dosage uncertain
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - Dosage uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
PYRIDOXINE [VITAMIN B-6] - (Prescribed by Other Provider) -
Dosage uncertain
SENNA - (Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. Outpatient Lab Work
weekly chem7, lft's, cbc w/diff, esr, crp.
All laboratory results should be faxed to ID R.Ns. at ([**Telephone/Fax (1) 39789**]
2. Rosuvastatin 5 mg [**Telephone/Fax (1) 8426**] Sig: Two (2) [**Telephone/Fax (1) 8426**] PO DAILY
(Daily).
3. Citalopram 20 mg [**Telephone/Fax (1) 8426**] Sig: Two (2) [**Telephone/Fax (1) 8426**] PO DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Acetaminophen 325 mg [**Telephone/Fax (1) 8426**] Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Ranitidine HCl 150 mg [**Telephone/Fax (1) 8426**] Sig: One (1) [**Telephone/Fax (1) 8426**] PO BID (2
times a day).
7. Aspirin 81 mg [**Telephone/Fax (1) 8426**], Chewable Sig: One (1) [**Telephone/Fax (1) 8426**], Chewable
PO DAILY (Daily).
8. Levothyroxine 100 mcg [**Telephone/Fax (1) 8426**] Sig: Three (3) [**Telephone/Fax (1) 8426**] PO DAILY
(Daily).
9. Bisacodyl 5 mg [**Telephone/Fax (1) 8426**], Delayed Release (E.C.) Sig: Two (2)
[**Telephone/Fax (1) 8426**], Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for gi upset/constipation.
11. Metoprolol Succinate 25 mg [**Telephone/Fax (1) 8426**] Sustained Release 24 hr
Sig: One (1) [**Telephone/Fax (1) 8426**] Sustained Release 24 hr PO DAILY (Daily).
12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-7**]
Puffs Inhalation Q6H (every 6 hours).
13. Lisinopril 10 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO DAILY
(Daily).
14. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
16. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
17. Furosemide 40 mg IV DAILY
18. Ondansetron 4 mg IV Q8H:PRN nausea
19. Warfarin 1 mg [**Month/Day (2) 8426**] Sig: One (1) [**Month/Day (2) 8426**] PO once a day: MD
to dose daily for goal INR 2.5-3.5, dx: mechanical aortic valve.
20. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale.
21. Outpatient Physical Therapy
Wound vac to left lower extremity leg wound:
Wound care:
Site: LLE
Type: Surgical
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: VAC, Continuous, Black Foam, Target Presure 125 mm Hg
Change dressing: Q72hrs
22. Outpatient Physical Therapy
LLE knee site- moist to dry dressing changes [**Hospital1 **]
23. Penicillin G Potassium 4 million units IV Q4H
x 4weeks (through [**2165-6-5**])
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Sepsis
Lower extremity cellulitis
morbid obesity
diabetes mellitus type II
aortic stenosis
coronary artery disease
pericardial tamponade
chronic venous stasis
chronic atrial fibrillation
systolic and diastolic CHF
urinary tract infection
obstructive sleep apnea
post thyroidectomy hypothyroidism
PSH:
Aortic valve replacement(25mm St. [**Male First Name (un) 923**] mechanical), aortic root
enlargement, coronary artery bypass grafts x 4(LIMA-LAD,
SVG-Dg,SVG-OM,SVG-AM) [**2165-3-26**]
thyroidectomy
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 3 weeks.
Follow-up with [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2165-6-27**] 2:00
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) **]
weekly chem7, lft's, cbc w/diff, esr, crp.
All laboratory results should be faxed to ID R.Ns. at ([**Telephone/Fax (1) 39789**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2165-6-4**] 8:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2165-5-26**]
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,457
| 142,417
|
1563+1578+55293
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2150-2-25**] Discharge Date: [**2150-3-14**]
Date of Birth: [**2085-5-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
[**2150-2-25**]: Left sided craniotomy for subdural evacuation
History of Present Illness:
64 y/o M with CAD s/p CABG x 2 and ruptured chordae tendinae s/p
mechanical mitral valve placement in [**1-11**] admitted to the
neurosurgical service on [**2-25**] for emergent evacuation of left
subdural hematoma (surgery on [**2-25**]) after falling and hitting
his head on the ice two days prior. Anticoagulation was reversed
with FFP and vitamin K. He did well postoperatively and a
heparin bridge was begun on [**3-2**], followed by the addition of
coumadin on [**3-5**]. His INR (1.7) has yet to become therapeutic
(2.5-3.5).
Past Medical History:
[**1-11**] Cardiac Surgery
-mechanical MV placement [**3-9**] chordae rupture following IE
-CABG x 2 (LIMA to LAD, SVG to Diag)
-PFO closure
-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
CAD
Permanent AFib s/p MAZE
DMII
COPD
Gout
Anxiety/Depression
s/p cataract surgery
Social History:
Retired electrical engineer. Lives at home alone. Has a
girlfriend in the area. Friend, [**Name (NI) 553**] [**Name (NI) 174**], is legal HCP
([**Telephone/Fax (1) 9082**]). Quit smoking [**10-12**] after 100 pack-years.
Family History:
Mother had CAD and colon CA in her mid 70's. Father had COPD.
Physical Exam:
ADMISSION PHYSICAL EXAM
O: Afebrile, stable
Gen: WD/WN, appears in pain.
HEENT: normocephalic, atraumatic.
Pupils: PERRL EOMs: intact, with lateral nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,with lens
implant; 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally with
nystagmus in the lateral gaze.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-9**] throughout. No pronator drift
Sensation: Intact to light touch
On Discharge:
AOx3, bilateral surgical pupils, full strength and power
throughout upper and lower extremities.
Pertinent Results:
[**2150-2-25**] 08:30AM BLOOD WBC-14.2* RBC-3.70* Hgb-11.8*# Hct-32.7*#
MCV-88 MCH-31.9 MCHC-36.1* RDW-13.8 Plt Ct-217
[**2150-2-25**] 11:47AM BLOOD WBC-12.7* RBC-3.27* Hgb-10.5* Hct-28.5*
MCV-87 MCH-32.2* MCHC-36.9* RDW-14.5 Plt Ct-229
[**2150-2-26**] 01:43AM BLOOD WBC-21.2*# RBC-3.16* Hgb-10.1* Hct-28.0*
MCV-89 MCH-32.0 MCHC-36.1* RDW-14.4 Plt Ct-248
[**2150-2-27**] 05:33AM BLOOD WBC-16.9* RBC-2.79* Hgb-8.7* Hct-24.8*
MCV-89 MCH-31.3 MCHC-35.1* RDW-14.5 Plt Ct-183
[**2150-2-28**] 07:30PM BLOOD WBC-11.5* RBC-2.78* Hgb-9.0* Hct-25.2*
MCV-91 MCH-32.2* MCHC-35.5* RDW-14.5 Plt Ct-252
[**2150-3-1**] 06:50AM BLOOD WBC-12.0* RBC-2.84* Hgb-9.2* Hct-25.6*
MCV-90 MCH-32.4* MCHC-35.8* RDW-14.5 Plt Ct-263
[**2150-3-2**] 05:45AM BLOOD WBC-13.2* RBC-2.95* Hgb-9.4* Hct-26.4*
MCV-89 MCH-31.9 MCHC-35.7* RDW-14.5 Plt Ct-307
[**2150-3-3**] 05:33AM BLOOD WBC-10.9 RBC-3.15* Hgb-9.9* Hct-28.0*
MCV-89 MCH-31.4 MCHC-35.3* RDW-14.8 Plt Ct-328
[**2150-3-5**] 05:40AM BLOOD WBC-12.4* RBC-3.04* Hgb-9.7* Hct-27.5*
MCV-91 MCH-31.9 MCHC-35.2* RDW-14.7 Plt Ct-382
[**2150-3-7**] 07:45AM BLOOD WBC-11.6* RBC-3.21* Hgb-9.7* Hct-29.3*
MCV-91 MCH-30.3 MCHC-33.3 RDW-14.6 Plt Ct-426
[**2150-3-8**] 07:56AM BLOOD WBC-12.5* RBC-3.33* Hgb-10.4* Hct-30.2*
MCV-91 MCH-31.2 MCHC-34.4 RDW-14.4 Plt Ct-473*
[**2150-3-10**] 05:55AM BLOOD WBC-10.9 RBC-3.22* Hgb-9.9* Hct-29.0*
MCV-90 MCH-30.9 MCHC-34.2 RDW-14.4 Plt Ct-461*
[**2150-3-12**] 07:50AM BLOOD WBC-9.9 RBC-3.42* Hgb-10.7* Hct-31.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-14.2 Plt Ct-505*
[**2150-3-13**] 09:05AM BLOOD WBC-9.2 RBC-3.55* Hgb-10.8* Hct-32.0*
MCV-90 MCH-30.4 MCHC-33.7 RDW-14.2 Plt Ct-508*
[**2150-3-14**] 08:00AM BLOOD WBC-9.8 RBC-3.59* Hgb-10.7* Hct-32.6*
MCV-91 MCH-29.8 MCHC-32.9 RDW-14.3 Plt Ct-494*
[**2150-2-25**] 06:42AM BLOOD PT-23.8* PTT-30.2 INR(PT)-2.3*
[**2150-2-25**] 08:30AM BLOOD PT-21.1* PTT-28.1 INR(PT)-2.0*
[**2150-2-25**] 11:47AM BLOOD PT-18.6* PTT-24.1 INR(PT)-1.7*
[**2150-2-26**] 01:43AM BLOOD PT-14.2* PTT-21.2* INR(PT)-1.2*
[**2150-3-5**] 05:40AM BLOOD PT-13.3 PTT-38.4* INR(PT)-1.1
[**2150-3-5**] 07:35PM BLOOD PT-14.6* PTT-60.6* INR(PT)-1.3*
[**2150-3-8**] 10:10PM BLOOD PT-15.9* PTT-96.4* INR(PT)-1.4*
[**2150-3-10**] 03:15PM BLOOD PT-16.7* PTT-56.2* INR(PT)-1.5*
[**2150-3-11**] 09:13PM BLOOD PT-19.0* PTT-72.0* INR(PT)-1.8*
[**2150-3-12**] 07:50AM BLOOD PT-21.4* PTT-95.8* INR(PT)-2.0*
[**2150-3-13**] 12:55AM BLOOD PT-22.9* PTT-120.6* INR(PT)-2.2*
[**2150-3-13**] 09:05AM BLOOD PT-23.3* PTT-75.0* INR(PT)-2.3*
[**2150-3-13**] 04:56PM BLOOD PT-22.0* PTT-53.2* INR(PT)-2.1*
[**2150-3-14**] 02:43AM BLOOD PT-22.9* PTT-69.7* INR(PT)-2.2*
[**2150-3-14**] 08:00AM BLOOD PT-24.9* PTT-97.4* INR(PT)-2.4*
[**2150-3-14**] 10:00AM BLOOD PT-25.1* PTT-92.9* INR(PT)-2.5*
[**2150-2-25**] 08:30AM BLOOD Glucose-170* UreaN-14 Creat-0.8 Na-138
K-4.8 Cl-103 HCO3-27 AnGap-13
[**2150-2-25**] 11:47AM BLOOD Glucose-195* UreaN-14 Creat-0.8 Na-138
K-5.2* Cl-105 HCO3-27 AnGap-11
[**2150-3-12**] 07:50AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.3 Iron-38*
IMAGING:
Head CT [**2-25**]:
IMPRESSION:
1. Large mixed but predominantly hyperdense left extra-axial
collection
consistent with acute subdural hematoma with gyral and lateral
ventricular
effacement, 9- mm rightward shift of midline structures and left
uncal
herniation.
2. Internal relatively low-attenuation foci may represent
non-clotted blood
from hyperacute hemorrhage, related to active bleeding.
3. Small right frontal extra-axial, likely subdural hematoma.
4. No fracture.
Head CT [**2150-2-25**] (post-evacuation):
IMPRESSION:
1. Status post virtual-complete evacution of left convexity
subdural hematoma with expected post-surgical changes including
bifrontal subdural
pneumocephalus.
2. Unchanged subdural blood layering along the tentorial
margins, as
described.
Head CT [**2150-3-4**]
IMPRESSION: Status post evacuation of subdural hematoma layering
over the
left cerebral convexity, without evidence of new intracranial
hemorrhage,
mass effect or herniation. The CSF-atttenuation fluid,
occupying the more anterior portion of the left frontal extra-
axial space, was present on the initial scan of [**2150-2-25**], and may
reflect decompression and re-expansion of pre-existent
compartmentalized subdural space, or true hygroma.
Head CT [**2150-3-13**]
FINDINGS: The patient is status post left frontoparietal
craniotomy with
expected amount of pneumocephalus, which has decreased compared
to the prior study. There is a small amount of remaining blood
products in the left frontal convexity consistent with expected
evolution of left subdural
hematoma. There is no evidence of new hemorrhage, mass effect,
or major
vascular territory infarction. There is no hydrocephalus or
herniation. There has been an interval decrease in left
frontoparietal subgaleal soft tissue edema. Visualized paranasal
sinuses and mastoid air cells remain well aerated. As before, no
lens is identified within the right globe.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or major
vascular territory infarction.
2. Status post craniotomy with expected evolution in remaining
blood products and decrease in pneumocephalus.
Brief Hospital Course:
#Bifrontal subdural hematoma evacuation - The patient did well
postoperatively following left craniotomy and evacuation of SDH
on [**2150-2-25**]. Neurological exam remained normal. Blood pressure
was closely monitored. Primary seizure prophylaxis was achieved
initially with dilantin and then with keppra, to be continued
after discharge. Heparin gtt was started on POD#5 followed by
coumadin on POD#8. Therapeutic INR was achieved without any
evidence of progression of SDH by CT. Physical therapy did not
recommended any post-discharge services. He will have his INR
checked 5 days after discharge. The patient will follow up with
neurosurgery 4 weeks after discharge.
.
#Mechanical mitral valve - TTE on [**3-2**] showed a well-seated
prosthesis with normal disc motion and transvalvular gradients,
without MR. Heparin bridge to therapeutic anticoagulation with
warfarin was achieved, as above, with a goal INR 2.5-3.5. The
patient was instructed to abstain from alcohol or starting new
medications until a stable coumadin level is established. He
will continue to be managed by the [**Company 191**] ACMS. It was recommended
that he follow up with his cardiologist [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 9083**] of [**Location (un) 9084**], MA.
.
#DMII - Serial elevated fasting glucose confirmed the diagnosis
of DMII. Metformin was started and well-tolerated prior to
discharge.
.
#CAD - Restarted aspirin prior to discharge. [**Month (only) 116**] benefit from
initiating beta-blockade as an outpatient if reactive airway
disease permits.
.
#Iron-deficiency anemia - Hematocrit remained stable, obviating
the need for blood transfusion. [**Month (only) 116**] benefit from iron
supplementation as outpatient. Outpatient colonoscopy
recommended.
.
#COPD - Continued the outpatient regimen.
Medications on Admission:
ASA 81 mg
Albuterol INR
Advair 500/50 [**Hospital1 **]
Symbicort 160/4.5 [**Hospital1 **]
Lasix 40 mg daily
Singulair 10 mg daily
Simvastatin 20 mg daily
Spiriva 18 mcg daily
Warfarin 15 mg daily
Ranitidine 150 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Ambien 10 mg QHS/PRN insomnia
Colchicine daily/PRN gout flare
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: Two
(2) Tablet PO every twelve (12) hours.
Disp:*28 Tablet(s)* Refills:*0*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation twice a day.
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain: as needed for gout flare.
9. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1) Acute bilateral subdural hematoma
2) Mechanical mitral valve replacement
3) Type II Diabetes
4) Iron deficiency anemia
Secondary
1) Coronary artery disease
2) Chronic obstructive pulmonary disease
3) Hyperlipidemia
4) Gout
Discharge Condition:
Asymptomatic with stable vital signs and normal neurological
exam.
Discharge Instructions:
You were admitted to the hospital after a fall with bleeding
outside of the brain, also known as subdural hematoma. Surgery
to remove the blood was performed on [**2150-2-25**] without
complications.
Please follow these recommendations for dosing your coumadin:
If your INR upon discharge is 2.5-3.5, take the following doses
of coumadin:
-10 mg Saturday and Sunday nights
-12.5 mg Monday night
-10 mg Tuesday night
-12.5 mg Wednesday night
-Have your coumadin level (INR) checked at [**Hospital3 **] on
Thursday, [**3-19**] and sent to the [**Hospital3 **]
on Thursday for further coumadin dosing.
Please continue to take Fiorecet for headaches until your INR
has stabilized. Fiorecet can affect the INR and your dose of
Fiorecet should be the same until you see Dr. [**Last Name (STitle) **] who will
decrease it.
Please do not take aspirin when you are discharged. You can
resume taking this 1 week after discharge.
**Please notify the [**Hospital3 **] Anticoagulation
[**Hospital 9085**] Clinic of any new medications.
**Please avoid alcohol until a stable dose of coumadin is
established.
You were also diagnosed with type II diabetes and started on a
medication called metformin (glucophage) to treat this
condition.
The following medication changes were made:
1) Keppra (Levetiracetam) was started to prevent a seizure.
2) Metformin (Glucophage) was started to treat diabetes.
3) Fiorecet 2 tablets every 12 hours for headaches.
The following are recommendations from your neurosurgery team:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam) but you
will not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Neurosurgery within 4 weeks' time.
??????Inform the person who books your appointment that you will need
a CT scan of the brain without contrast prior to the
appointment.
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-6**] weeks. Please follow-up
with the [**Hospital3 **] for your coumadin dosing.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2150-5-15**] 2:40
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2150-5-29**] 9:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2150-5-29**] 10:00
Completed by:[**2150-3-15**] Admission Date: [**2150-3-19**] Discharge Date: [**2150-3-22**]
Date of Birth: [**2085-5-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
subtherapeutic INR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64M PMH mechanical MVR, recent admission for SDH s/p evacuation
p/w subtherapeutic INR. The patient was discharged [**2150-3-14**]
after a two-week hospitalization for SDH. His INR was noted to
be 1.7 the day of admission and he was sent to the ED for
heparin gtt. He had taken his prescribed coumadin 15 mg PO
today. He believes he has been complaint with his coumadin, but
admits to some confusion regarding his medications as he was
recently discharged with several new medications. Per notes he
complained of somnulence earlier, but currently denies.
.
In the ED, VS 98.4 112/67 54 20 99%RA. CT head negative for
acute change. He was given coumadin 2.5 mg PO after discussion
with the patient's PCP and was started on heparin gtt.
.
On arrival to the floor, the patient has no specific complaints.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
[**1-11**] Cardiac Surgery
-mechanical MV placement [**3-9**] chordae rupture following IE
-CABG x 2 (LIMA to LAD, SVG to Diag)
-PFO closure
-[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation
CAD
Permanent AFib s/p MAZE
DMII
COPD
Gout
Anxiety/Depression
s/p cataract surgery
Social History:
Retired electrical engineer. Lives at home alone. Has a
girlfriend in the area. Friend, [**Name (NI) 553**] [**Name (NI) 174**], is legal HCP
([**Telephone/Fax (1) 9082**]). Quit smoking [**10-12**] after 100 pack-years.
Family History:
Mother had CAD and colon CA in her mid 70's. Father had COPD.
Physical Exam:
VS: 110/65, HR 50, RR 20, O2 Sat 95% on RA
Gen: appears comfortable
Neuro: A&O x 3, coherent, no neuro deficits noted
HEENT: head scar healing well, no hematoma, moist MM, oropharynx
clear
Heart: regular, bradycardic, no murmurs
Lungs: clear bilaterally
Abdomen: soft, nontender, nondistended
Extremities: warm, no edema
Pertinent Results:
Admission labs:
[**2150-3-19**] 05:35PM WBC-8.5 RBC-3.69* HGB-11.0* HCT-32.6* MCV-88
MCH-29.8 MCHC-33.7 RDW-14.4
[**2150-3-19**] 05:35PM NEUTS-65.4 LYMPHS-26.6 MONOS-5.0 EOS-2.2
BASOS-0.8
[**2150-3-19**] 05:35PM GLUCOSE-101 UREA N-17 CREAT-0.9 SODIUM-143
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-29 ANION GAP-14
Coagulation parameters:
[**2150-3-19**] 05:35PM BLOOD PT-19.8* PTT-27.9 INR(PT)-1.8*
[**2150-3-20**] 01:15AM BLOOD PT-19.9* PTT-38.6* INR(PT)-1.9*
[**2150-3-21**] 04:25AM BLOOD PT-23.0* PTT-86.9* INR(PT)-2.2*
[**2150-3-22**] 07:55AM BLOOD PT-26.6* PTT-112.6* INR(PT)-2.6*
Brief Hospital Course:
A 63 year-old man with a history of mechanical mitral valve
presents with subtherapeutic INR.
.
# Subtherapeutic INR: Goal 2.5-3.5, admitted for heparin bridge
given high risk nature of a mechanical mitral valve. He was
started on heparin with goal PTT 60-100, and coumadin was dosed
daily. In consultation with [**Company 191**] anticoagulation team, he
received 17.5 mg coumadin for two days then 15 mg for one day.
INR rose to 2.6 and he was discharged with plans for repeat INR
[**3-24**].
Given the patient's confusion around his medications, home VNA
was arranged prior to discharge for medication reconciliation.
.
# Bradycardia: Asymptomatic. No evidence of cause of increased
ICP on head imaging, and not hypertensive. During last
hospitalization HR mostly 60s.
.
# Anemia: At recent baseline.
.
# Status post SDH evacuation: CT head on admission negative for
acute change. Keppra was continued for seizure prophylaxis.
.
# COPD/emphysema: Patient was asymptomatic, with normal O2 Sats,
advair (instead of symbicort), spiriva, albuterol were
continued.
.
# Type 2 diabetes: Metformin was continued; he was given
insulin SS.
.
# History of atrial fibrillation: Status post MAZE procedure. In
sinus bradycardia. Anticoagulation as above.
.
# Hypercholesterolemia: Atorvastatin was continued.
.
.
Medications on Admission:
1. Warfarin 15 mg PO DAILY
2. Metformin 500 mg PO DAILY
3. Keppra 1,000 mg PO BID
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Two Tablets
PO Q12H - no longer taking
5. Albuterol Sulfate Inhaler 1-2 Puffs Inhalation every [**5-11**]
hours as needed for shortness of breath or wheezing.
6. Fluticasone-Salmeterol 500-50 mcg/Dose 1 Puff Inhalation [**Hospital1 **]
7. Montelukast 10 mg PO DAILY
8. Colchicine 0.6 mg PO DAILY:PRN gout flare
9. Symbicort 160-4.5 mcg Inhaler 2 puffs [**Hospital1 **]
10. Simvastatin 20 mg PO DAILY
11. Tiotropium Bromide 18 mcg 1 Cap Inhalation DAILY
12. Furosemide 40 mg PO DAILY
13. Zolpidem 10 mg PO HS:PRN insomnia
14. Ranitidine HCl 150 mg PO BID
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
12. Coumadin 2.5 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*0*
13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day:
prn gout flare.
14. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Outpatient Lab Work
coagulation profile. INR
[**2150-3-24**]
Please fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 9190**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
primary: mechanical mitral valve, subtherapeutic INR
secondary: atrial fibrillation, type 2 diabetes mellitus,
hyperlipidemia, anxiety, chronic obstructive pulmonary disease,
coronary artery disease
Discharge Condition:
stable, INR 2.6
Discharge Instructions:
You were admitted to the hospital because your INR (marker of
warfarin level) was too low. You were given IV heparin until
your INR was correct.
Your fioricet was stopped. Please do not take this medication,
as it may affect your INR. Your warfarin dose was changed to
12.5mg daily. You must have your INR checked on tuesday.
Please call your doctor or return to the hospital if you have
chest pain, shortness of breath, high fevers and chills, or
other symptoms that are concerning to you.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please follow up with your primary care provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**],
MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-3-26**] 10:40
Also please follow up as previously scheduled:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2150-4-9**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8364**], MD Phone:[**Telephone/Fax (1) 1669**]
Date/Time:[**2150-4-9**] 3:30
.
Please be sure to have your INR checked tuesday at [**Hospital1 9191**].
Completed by:[**2150-3-23**] Name: [**Known lastname **],[**Known firstname **] G Unit No: [**Numeric Identifier 1214**]
Admission Date: [**2150-3-19**] Discharge Date: [**2150-3-22**]
Date of Birth: [**2085-5-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1215**]
Addendum:
The patient received a dose of 12.5 mg of warfarin prior to
leaving the hospital on the day of discharge, [**2150-3-22**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 328**] VNA
[**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 1216**] MD [**MD Number(2) 1217**]
Completed by:[**2150-3-24**]
|
[
"E885.9",
"852.21",
"427.31",
"428.20",
"274.9",
"401.9",
"V58.61",
"V43.3",
"V45.81",
"414.00",
"348.8",
"790.92",
"250.00",
"280.9",
"428.0",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
24242, 24456
|
18669, 19980
|
16013, 16019
|
22457, 22475
|
18056, 18056
|
23114, 24219
|
17636, 17699
|
20721, 22134
|
22233, 22436
|
20006, 20698
|
22499, 23091
|
17714, 18037
|
2546, 2644
|
15955, 15975
|
16047, 17061
|
1914, 2532
|
18073, 18646
|
1792, 1898
|
17083, 17381
|
17397, 17620
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,072
| 146,728
|
27286
|
Discharge summary
|
report
|
Admission Date: [**2167-5-11**] Discharge Date: [**2167-5-20**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Exertional Angina
Major Surgical or Invasive Procedure:
[**2167-5-13**] - CABG x 2, AVR (21mm [**Last Name (un) 66915**] Bovine Pericardial)
[**2167-5-11**] - Cardiac Catheterization
History of Present Illness:
CC:[**Last Name (NamePattern1) 66916**]
HPI: Patient reports several month history of exertional
anterior
chest pain associated with shortness of breath. Patient denies
complaints of PND, orthopnea, N/V,diaphoresis or recent LE
edema.
He does report occasional lightheadedness and palpatations.
[**2-9**] Echo showed EF 65-70%, calcific mild to moderate aortic
stenosis, [**Location (un) 109**] 1.2 cm2, trace AI and 1+MR.
[**2167-5-11**] Patient was scheduled for an elective ETT-->exercised
3minutes and 43 seconds. Test discontinued due to fatigue, SOB
and trace chest pain. ECG notable for 3.0mm ST depression in
Lead
II, 2.0mm ST depression in V5-6, 1.5mm J point depression in
III,F and V4. Patient had resolution of symptoms at 6 minutes
and
ECG returned to baseline. Given the markedly positive findings
at
a low workload arrangements were made to transfer patient for
cardiac cath. He presented to the holding area in stable
condition, pain free.
Of note, patient has recently been undergoing an OPT work-up to
determine the etiology of his chronic anemia. [**3-9**] Upper GI
series significant for hiatal hernia, atrophic gastritis. Lower
GI series showed evidence of internal hemmoroids, colon polyp
and
diverticulosis.
Past Medical History:
Hypercholesterolemia
HTN
Iron deficiency anemia
BPH
Hiatal hernia
Diverticulosis
Bilateral lens implants
Right TKR
Prior Smoker
Social History:
Lives with significant other in [**Name (NI) 620**], [**Name (NI) **]. Retired.
Family History:
Notable for coronary artery disease
Physical Exam:
PE: Alert and orientd. Denies chest pain or SOB.
Ht: 5'8"
Wt: 155 lbs.
VSS: 74 (SR), 150/82
Neck: carotids 1+, bilateral bruits probably related to murmur
radiation
Heart: S1,S2 +[**4-9**] AS murmur
Lungs: clear with scattered exp wheezing noted; O2 sat 96% RA
Abdomen: Soft, nontender, +BS, no bruits
Pulses: R L
Femoral 2+ 1+ no bruits
DP 1+ tr+
PT tr+ dop+
Extremities: [**Last Name (un) **] warm, trace ankle edema
ECG: SR,66 no ischemic changes noted
Pertinent Results:
[**2167-5-11**] 05:20PM GLUCOSE-139* UREA N-29* CREAT-1.4* SODIUM-135
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-24 ANION GAP-12
[**2167-5-11**] 05:20PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-78 TOT
BILI-0.3
[**2167-5-11**] 05:20PM ALBUMIN-3.6
[**2167-5-11**] 01:55PM PT-12.3 PTT-24.5 INR(PT)-1.1
[**2167-5-11**] 01:55PM PLT COUNT-383
[**2167-5-11**] 01:55PM GLUCOSE-99 UREA N-32* CREAT-1.6* SODIUM-139
POTASSIUM-5.9* CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
[**2167-5-11**] 05:20PM WBC-4.7 RBC-3.44* HGB-9.2* HCT-29.2* MCV-85
MCH-26.7* MCHC-31.5 RDW-22.1*
[**2167-5-11**] Cardiac Catheterization
1. Selective coronary angiography revealed a right dominant
system.
There was a 50% distal LM stenosis involving the origin of the
LAD. The
LAD had a 95% stenosis originating from the LM plaque. There was
a 40%
ramus stenosis. The LCX was nonobstructed. The RCA had a 40-50%
mid
vessel stenosis.
2. Hemodynamics on entry showed mild aortic stenosis with a
gradient of
16 mm Hg across the aortic valve and a valve area of 1.1 cm2.
There was
LV diastolic dysfunction (LVEDP 19 mm Hg) and a normal cardiac
output
(4.5).
[**2167-5-13**] Panorex
Single Panorex view of the mandible shows only a few remaining
central lower teeth. It is difficult to assess whether small
caries are present in these teeth but no bone destruction and
the visualized lower maxillary sinuses are normally aerated. TM
joints not visualized.
[**2167-5-12**] Carotid Duplex Ultrasound
No appreciable plaque or wall thickening involving either
carotid system. The peak systolic velocities are normal
bilaterally as are the ICA to CCA ratios. There is normal
antegrade flow involving both vertebral arteries.
[**2167-5-15**] ECHO
Conclusions:
Suboptimal study. Only limited views obtained.
1.There is mild symmetric left ventricular hypertrophy. Due to
suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded.
Overall left ventricular systolic function is normal (LVEF>55%).
2.The prosthetic aortic valve is not well seen.
3.The mitral valve is not well seen.
4.There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 66917**] was admitted to the [**Hospital1 18**] on [**2167-5-11**] for further
evaluation of his exertional angina and positive exercise
tolerance test. He underwent a cardiac catheterization which
revealed severe aortic stenosis as well as left main and single
vessel coronary artery disease. Given the severity of his
disease, the cardiac surgical service was consulted for surgical
management. Mr. [**Known lastname 66917**] was worked-up in the usual preoperative
manner including a carotid duplex ultrasound which revealed
normal internal carotid arteries. A dental consult was obtained
for oral clearance for surgery. After obtaining a panorex film,
Mr. [**Known lastname 66917**] was cleared for valve surgery from an oral
standpoint. On [**2167-5-13**], Mr. [**Known lastname 66917**] was taken to the operating
room where he underwent coronary artery bypass grafting to two
vessels and an aortic valve replacement utilizing a 21mm [**Doctor Last Name **]
Pericardial valve. Postoperatively, he was taken to the cardiac
surgical intensive care unit for monitoring. On postoperative
day one, Mr. [**Known lastname 66917**] [**Last Name (Titles) 5058**] neurologically intact and was
extubated. Aspirin, beta blockade and a statin were resumed. He
was then transferred to the cardiac nursing floor for further
recovery. He was gently diuresed towards his preoperative
weight. On postoperative day two, Mr. [**Known lastname 66917**] developed torsades
de pointes requiring defibrillation and 1 gram of magnesium. He
was intubated and returned to the intensive care unit for
monitoring. The cardiology service was consulted for assistance
in his care. Amiodarone was loaded and he was extubated
successfully later on postoperative day two. He was transferred
to back to the floor on postoperative day five. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. His amiodarone was switched
to an oral dose. He continued to make steady progress and was
discharged home on postoperative day seven. He will follow-up
with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician
as an outpatient.
Medications on Admission:
Aspirin
Lipitor
Triamterene
Iron
Flomax
Zantac
Occuvite
Lumagen
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 2 tablets (400 mg) x 6 days, then 200 mg (1 tablet)
ongoing until dc'd by cardiologist.
Disp:*45 Tablet(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
HTN
Hypercholesterolemia
AS
CRI
Fe deficiency anemia
BPH
Hiatal hernia
Diverticulosis
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage form incision or weight
gain more than 2 poundsin one day or five in one week.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Shower, no baths, no lotions creams or powders to incision.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 5293**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
[**Hospital Ward Name 121**] 2 Nurses 2 weeks after surgery for wound check, staple
removal
Completed by:[**2167-5-26**]
|
[
"997.1",
"428.0",
"414.01",
"424.1",
"272.4",
"427.5",
"413.9",
"427.41",
"V15.82",
"593.9",
"996.01",
"401.9",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"36.15",
"96.71",
"39.61",
"88.56",
"36.11",
"89.60",
"99.62",
"38.93",
"96.04",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
8483, 8532
|
4680, 6873
|
286, 414
|
8662, 8670
|
2555, 4657
|
8966, 9207
|
1939, 1976
|
6987, 8460
|
8553, 8641
|
6899, 6964
|
8694, 8943
|
1991, 2536
|
229, 248
|
442, 1675
|
1697, 1826
|
1842, 1923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,393
| 110,783
|
53635
|
Discharge summary
|
report
|
Admission Date: [**2138-9-17**] Discharge Date: [**2138-9-21**]
Date of Birth: [**2056-10-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
acute onset chest tightening, dizziness, diaphoresis, and
shortness of breath
Major Surgical or Invasive Procedure:
coronary catherterization
History of Present Illness:
81 y old male with hx of dyslipidemia, HTN, CAD s/p NQWMI in '[**32**]
s/p bare metal stenting of proximal and mid LAD as well as OM1
presented to ED by ambulance with acute onset chest tightening,
dizziness, diaphoresis, and shortness of breath, was found to
have STE >5mm in II, III, aVF, V4-V6 along with 3-4mm ST
depression in I and aVL. Hr was in the 40s. Code STEMI was
called, pt was given ASA 325mg, plavix 600mg (although takes
plavix at home), Heparin 5000 units x 1, Integrillin 17mg IVx1
and then transferred to cath lab. In cath lab pt had
successfull bare metal stenting to proximal RCA and was also
found to have new diffuse aneurysmla dilatation of his vessels.
Pt became bardycardic intermittently in the cath lab and
required atropine x2. Temporary pacer placed prior to the
transfer to the floor.
When pt seen on on the floor he denied any chets pain, sob,
diaphoresis, nausea. States onset of chest pain was in the
setting of the culmination of a 16 day editing project he had as
a composer. Pt quickly realized the urgency of the situation as
the sx's very similar to his prior MI and therefore asked his
friend to [**Name2 (NI) **] 911.
Of note, pt states he was on ASA 325mg up until about 2 years
ago when he was noted to have "blood from below". Per pt he was
told to stop taking the ASA and never had a GI w/u for the
bleeding as he states "it was assumed that the bleeding was due
to apirin". His last colonoscopy was 7-8 years ago and was
normal. he has never had an EGD.
At home pt exercises by "speed-walking" on a treadmill for 30
minutes almost every day and never experiences any anginal sx's
or SOB. He has never smoked, drinks occasionally and tries to
adhere to a fairly low fat diet.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis,
recent black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
.
Cardiac review of systems when seen on the floor is notable for
absence of chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
# CAD s/p NQWMI in '[**32**] s/p bare metal stenting of proximal and
mid LAD as well as OM1
# HTN
# Dyslipidemia
# Hx of ulcers on feet bilaterally
# R eye blind after traumatic injury at age 11
Social History:
Social history is significant for the absence of tobacco use.
Occasional alcohol.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 96.4, BP 98/69, HR 62, RR 19, SaO2 100% on 2L
Gen: male appearing younger than stated age in NAD. Oriented x3.
Mood, affect appropriate. Pleasant.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: No JVD
CV: RR, normal S1, S2. No S4, no S3.
Chest: Resp were unlabored, no accessory muscle use. No
crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: Both feet with toes in dorsiflexion appearing like
contractures. Also with superficila fungal infections of toes
and nails. Both legs with brown discoloration of feet up to
mid-calf.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: Femoral 2+ without bruit bil; 1+ DP bil.
Pertinent Results:
[**2138-9-17**] 08:45PM GLUCOSE-126* UREA N-20 CREAT-1.2 SODIUM-140
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-16
[**2138-9-17**] 08:45PM estGFR-Using this
[**2138-9-17**] 08:45PM CK(CPK)-115
[**2138-9-17**] 08:45PM cTropnT-<0.01
[**2138-9-17**] 08:45PM CK-MB-5
[**2138-9-17**] 08:45PM WBC-7.9 RBC-5.18 HGB-16.4 HCT-49.4 MCV-95
MCH-31.7 MCHC-33.2 RDW-14.5
[**2138-9-17**] 08:45PM NEUTS-39.3* LYMPHS-51.5* MONOS-6.8 EOS-2.0
BASOS-0.4
[**2138-9-17**] 08:45PM PLT COUNT-189
[**2138-9-17**] 08:45PM PT-13.7* PTT-27.3 INR(PT)-1.2*
.
Echo ([**9-19**]):
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
inferolateral wall. The remaining segments contract normally
(LVEF = 45-50 %). The aortic root is moderately dilated at the
sinus level. The ascending aorta is moderately dilated. The
aortic arch is mildly dilated. The aortic valve leaflets are
mildly thickened. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction c/w
CAD. Mild aortic regurgitation. Mild mitral regurgitation.
Dilated thoracic aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2130-12-21**], the regional left ventricular wall
motion abnormality is new and the ascending aorta and arch are
now identified as dilated.
CLINICAL IMPLICATIONS:
Based on [**2137**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Pt with presentation to [**Hospital1 18**] as mentioned above, taken to cath;
in cath lab pt had successfull bare metal stenting to proximal
RCA and was also found to have new diffuse aneurysmal dilatation
of his vessels. Pt became bardycardic intermittently in the
cath lab and required atropine x2. Temporary pacer placed prior
to the transfer to the CCU. In the CCU where pt was placed on
tele. On the second day the pace was briefly needed but then
heart rate remained in to 60-s and 70s, therefore the pacer was
removed after 48hrs, lopressor was again started after 72 hrs
without a drop in the heart rate (bradycardia improved as
expected since RCA reperfused)
Enzymes were negative in the emergency room, but second set came
back VERY elevated at CK 2713, Trop T 11.23, CK-MB 363 and MB
index of 13.4. Ezymes thereafter trended down. Medically,
plavix 75 mg was continued, atorvastatin 80mg was started (for
pleotropic effects, i.e. anti-inflammatory ect, and for
mortality benefits), ASA 325 mg was restarted in hosp on
admission. The reason for pt not taking it the past 2 years
prior to presentation was cleared up with PCP who stated this
was b/c pt had nose bleeds during his performances, and
therefore elected not to take ASA anymore. PCP agrees pt needs
to be on lifelong ASA and plavix and will follow up closely in
the case of another bleed. ACEI was held on presentation due to
concern of droing BP with bradycardia but restarted on HOD#2. An
echo was done to r/o wall motion abnormalities determine EF
demonstrating mild symmetric left ventricular hypertrophy with
regional systolic dysfunction, and LVEF = 45-50 % c/w CAD.
Pt was evaluated by PT who found patient fit to go home since pt
ambulated for 15 minutes at a fast rate without any CP or SOB.
Upon discharge pt was asymptomatic, and ambulating, voiding,
taking good po on own, and saturating well off oxygen.
Medications on Admission:
Altace (ramipril) 5mg qday
Toprol XL 25 mg qday
Isosorbide Mononitrate 30 mg qday
Lipitor 10mg qday
Plavix 75 mg qd
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial infarction (Inferior STEMI)
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] with an ST elevation myocardial
infarction.
Please take your previous medications as prescribed. The
following changes has been made to your medications:
- please start taking aspirin 325mg daily for secondary
cardiovascular prevention (to prevent another heart attack) and
atorvastatin 80mg daily for your heart and for your cholesterol.
- please stop taking isosorbide mononitrate
If you develop chest pain, jaw pain, or chest pressure with pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
Followup Instructions:
Please call your PCP for an appointment within 1-2 weeks.
|
[
"401.9",
"427.89",
"E879.8",
"410.71",
"429.9",
"424.0",
"997.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.06",
"00.66",
"88.53",
"00.45",
"37.78",
"00.40",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8609, 8615
|
6016, 7912
|
402, 429
|
8698, 8707
|
3954, 5734
|
9377, 9438
|
3083, 3165
|
8078, 8586
|
8636, 8677
|
7938, 8055
|
8731, 9354
|
3180, 3935
|
5757, 5993
|
285, 364
|
457, 2750
|
2772, 2968
|
2984, 3067
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,202
| 146,841
|
13831
|
Discharge summary
|
report
|
Admission Date: [**2146-6-3**] Discharge Date: [**2146-6-11**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 61-year-old white male
with unknown previous medical history who was apparently well
until two days prior to admission when he last was seen at
work. Having been out of work for two days, he was found on
the morning of admission by friends and family in his home,
but naked and down and unresponsive. EMT found the patient
to be cold, not moving, with [**Location (un) 2611**] coma scale of 3. He was
taken to the [**Hospital6 8283**], intubated, CT scan
showed increased ventricular size, right greater than left
with a large subarachnoid hemorrhage at the base of the
brain. He was transferred by [**Location (un) **] to the [**Hospital1 346**]. He had been given Vecuronium times
one at 10 a.m. for "bucking" event but has had no spontaneous
movements of any kind of the limbs or head since that time.
Per the family, he had a CT scan done one week prior to
admission, subsequent to a fall. They were unaware of the
report or the result of that.
PAST MEDICAL HISTORY: Included a history of gout. His
current medications included Wellbutrin 100 mg per day and
Paxil 40 mg per day. Remainder of the history was
unobtainable at the time of admission.
PHYSICAL EXAMINATION: Vital signs 130/91, pulse 110,
respiratory rate 11, on ventilation at 100% saturation.
Heart was regular rate and rhythm without murmur, gallop or
rub. Pulmonary showed coarse bilateral breath sounds. Neuro
exam, he was unconscious and unresponsive and intubated.
There was left corneal erosion but fundi were within normal
limits. Pupils were non reactive. There were no corneal
reflex and negative Doll's eyes. There was no response to
noxious stimuli. The reflexes were diminished and the toes
were mute bilaterally.
HOSPITAL COURSE: Due to the clinical findings, the patient
was admitted to the hospital and seen urgently by Dr. [**Last Name (STitle) 1132**]
of the neurosurgery service who took the patient for urgent
angiogram which demonstrated a grade 5 subarachnoid
hemorrhage with a right SCA aneurysm which had ruptured and
he underwent an endovascular embolization of the right SCA
aneurysm. The patient tolerated the procedure well, was then
subsequently admitted to the surgical Intensive Care Unit.
He remained essentially unresponsive to all noxious stimuli
throughout the remainder of his hospitalization. He did have
a ventriculostomy drainage tube placed at the time of
admission and unfortunately for the remainder of the
patient's hospitalization he remained unresponsive and after
a family meeting and discussion with the family and
consistent with the family and patient's living will, the
patient was subsequently extubated and provided comfort
measures only beginning on [**6-11**] and he subsequently developed
bradycardia with eventual expiration at 11:55 a.m. on the
morning of [**2146-6-11**].
CONDITION: Deceased.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Name8 (MD) 22907**]
MEDQUIST36
D: [**2146-8-15**] 10:30
T: [**2146-8-18**] 21:12
JOB#: [**Job Number 41536**]
|
[
"996.2",
"435.8",
"276.5",
"430",
"410.71",
"728.89",
"458.9",
"437.3",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.41",
"39.79",
"96.6",
"02.42",
"39.50",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
1890, 3245
|
1345, 1872
|
150, 1116
|
1139, 1322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,541
| 102,539
|
52167
|
Discharge summary
|
report
|
Admission Date: [**2162-8-8**] Discharge Date: [**2162-8-30**]
Date of Birth: [**2078-11-3**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal Pain.
Major Surgical or Invasive Procedure:
[**2162-8-20**] Exploratory laparoscopy,lap assisted small bowel
resection
History of Present Illness:
This is an 83 year old woman with a history of CAD s/p CABG, R
sided HF on home O2 presenting with LLQ abdominal pain. Sharp
and intermittent squeezing pain in LLQ, [**7-18**] in severity on
admission; no n/v/d, no f/c, no dysuria/hematuria, BRBPR, or
melena. BM yesterday was normal. Never has experienced this type
of pain before; denies postprandial pain. Has had decreased
appetite over past week because has been feeling down due to
second husband's passing. Recently moved back from FL per her
[**Hospital1 **] request when they saw she was depressed.
Initial VS in the ED were T97 HR88 BP100/54 RR18 95% ra. Labs
showed evidence of a urinary tract infection (+WBC, Lg Leuk, Mod
Bx). Lactate was normal, CMP grossly normal, LFTs and lipase
normal. CBC showed a normal white count and a macrocytic anemia
with HCT of 33.1. CT abdomen showed a 12 cm segment of distal
small bowel with circumferential wall thickening and surrounding
mesenteric edema.
Received ciprofloxacn and metronidazole for UTI and vague GI
process. VS prior to transfer were T98.1 HR96 RR18 BP108/73 84
on r/a 91 2L. On the floor, metronidazole was discontinued.
This morning, she is feeling fine. Pain has resolved. Denies CP,
SOB, abdominal pain, n/v, diarrhea, melena, BRBPR. No BM yet
today, passing flatus. Has not eaten since admission. No
dysuria, hematuria.
Note she is unable to give details about any aspects of her
history, including prior diagnosis of UC. She denies any history
of recent diarrhea or BRBPR. Per notes from [**2156**], she was
diagnosed with UC due to symptoms of rectal bleeding and
diarrhea at that time, was on prednisone until [**2157**], when it was
discontinued. Also does not know why she is on prednisone, but
per PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **], it is for PMR.
Past Medical History:
CAD s/p angiogram on [**2147-12-18**] (50-60% mLAD, 70-80% dLAD, LCx
and RCA ok; medical therapy recommended), complex PCI on
[**2155-8-20**] (LMCA/LAD dissection during attempted Taxus stenting
of 80-90% pLAD stenosis-->3x20mm perfusion balloon passed into
LAD-->VT/VF and respiratory failure-->defibrillation, lidocaine,
amiodarone, pressors-->3x18mm Cypher DES to LMCA/pLAD-->flow
re-established-->IABP inserted-->emergent CABG (presumably
LIMA-LAD)
H/o pAF, seen by Dr [**Last Name (STitle) 1911**] here in [**2153**]; on quinidine; not
documented here prior to EKG on [**2162-8-13**]
HTN
HLD
HFpEF, on 80mg [**Hospital1 **] lasix at home
L-sided ulcerative colitis in remission
Infrarenal abdominal aortic aneurysm measuring up to 4 cm in
transverse diameter (noted previously, and again on CT here on
[**2162-8-8**])
H/o PE s/p IVC filter [**1-/2157**]
Hypothyroidism
Tobacco history
PMR, on prednisone at home
CCY
Appendectomy age 18
Inguinal hernia repair
Face lift age 50
Social History:
She is widowed. 60 pack-year history of smoking, stopped 30
years ago. No alcohol or coffee.
Family History:
Son has Crohn's disease.
Physical Exam:
EXAM ON ADMISSION:
VITALS: 98.3|106/86| HR 92| RR 18| 96% on 2L Wt. 73.1
GENERAL: Well appearing NAD. Pleasant.
HEENT: Anicteric sclera MMM. No cervical LAD
NECK: No carotid bruits.
LUNGS: Good inspiratory effort, CTAB with no wh/r/rh
HEART: Sternotomy scar. RRR, [**4-13**] crescendo decrescendo systolic
murmur along the LUSB. No heave or carotid radiations.
ABDOMEN: Protuberant abdomen. Soft, NBS. RLQ mildly tender to
deep palpation, no rebound or guarding. No organomegaly. No
suprapubic tenderness.
EXTREMITIES: Multiple scattered ecchymoses. Thin skin. LLE
bandaged from skin tear. Scant LE edema.
NEUROLOGIC: A+OX3. No focal CN deficits.
Pertinent Results:
CBC:
ADMISSION:
[**2162-8-8**] 07:30PM BLOOD WBC-5.6 RBC-3.12* Hgb-10.9* Hct-33.1*
MCV-106*# MCH-35.1* MCHC-33.0 RDW-13.4 Plt Ct-248
Diff: [**2162-8-8**] 07:30PM BLOOD Neuts-83.2* Lymphs-9.1* Monos-6.3
Eos-1.0 Baso-0.5
COAGS:
ADMISSION:
[**2162-8-9**] 06:54AM BLOOD PT-10.7 PTT-25.3 INR(PT)-1.0
ELECTROLYTES:
ADMISSION:
[**2162-8-8**] 07:30PM BLOOD Glucose-107* UreaN-27* Creat-1.0 Na-138
K-3.4 Cl-101 HCO3-28 AnGap-12
[**2162-8-9**] 06:54AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9 Iron-16*
LFTs:
ADMISSION:
[**2162-8-8**] 07:30PM BLOOD ALT-18 AST-18 AlkPhos-56 TotBili-0.3
[**2162-8-8**] 07:30PM BLOOD Lipase-43
[**2162-8-8**] 07:30PM BLOOD Albumin-3.9
Lactate: [**2162-8-8**] 07:38PM BLOOD Lactate-0.9
CRP: [**2162-8-9**] 06:54AM BLOOD CRP-37.0*
TSH: [**2162-8-9**] 06:54AM BLOOD TSH-2.0
Anemia work up:
[**2162-8-9**] 06:54AM BLOOD calTIBC-296 VitB12-190* Folate-GREATER TH
Ferritn-73 TRF-228
[**2162-8-9**] 06:54AM BLOOD Ret Aut-2.1
Micro:
[**2162-8-14**] URINE URINE CULTURE-PENDING
[**2162-8-14**] MRSA SCREEN MRSA SCREEN-PENDING
[**2162-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2162-8-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2162-8-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
Imaging:
[**2162-8-8**] CT abd/pelvis: 1. Approximately 12 cm segment of distal
small bowel with circumferential wall thickening and mild
associated mesenteric edema. Findings are concerning for
ischemic, infectious or inflammatory causes of small bowel
enteritis. Given the dense vascular calcifications, ischemic
etiologies are favored. However, the aortic branch vessels
appear patent without focal thrombus. 2. Infrarenal abdominal
aortic aneurysm measuring up to 4 cm in transverse diameter. 3.
Duodenal diverticulum. 4. Stable hepatic cysts.
[**2162-8-9**] KUB: There is a non-specific bowel gas pattern with air
seen in some loops of non-dilated small bowel as well as within
the colon. Contrast is seen in the colon and in the rectum. An
IVC filter is in place. There are splenic artery
calcifications. There is no evidence of free air or
degenerative changes in the lumbar spine. IMPRESSION:
Non-specific bowel gas pattern with no definite obstruction.
[**2162-8-10**] MRE: 1. Again noted is a 15-cm segment of mid-distal
ileum with wall thickening with edema and mild mucosal
hyperenhancement. These findings are most likely representative
of an ischemic/infectious etiology affecting the ileumand
unlikely to be Crohn's disease. Celiac artery, SMA, [**Female First Name (un) 899**] and
splanchnic veins do not show concerning findings. 2. 3.8 x
3.7 cm infrarenal abdominal aortic aneurysm. 3. Hepatic cysts
as described above. 4. Duodenal diverticulum.
[**2162-8-12**] KUB (prelim report): There are mildly dilated gas-filled
small bowel loops as well as decompressed colon with residual
oral contrast. There is no definite evidence of obstruction or
free air. An IVC filter is in place. There is contrast seen
within the large bowel and splenic artery calcifications.
Degenerative changes are noted in the spine. Median sternotomy
wires are present. IMPRESSION: Mildly dilated gas-filled small
bowel loops. No definite obstruction or free air.
[**2162-8-13**] CXR: The course of the nasogastric tube is unremarkable,
with the
exception of a slight deviation of the tube at the level of the
lower
esophageal third, suggesting the potential presence of a hiatal
hernia. The site of the tube is located at the gastroesophageal
junction, the tip of the tube projects over the proximal parts
of the stomach. The tube should be advanced by approximately 5
cm. There is no evidence of complication, notably no
pneumothorax. Mild retrocardiac areas of atelectasis.
[**2162-8-14**] LENI's: IMPRESSION: No evidence of deep venous thrombosis
in bilateral lower extremities.
[**2162-8-14**] TTE: The left atrium is mildly dilated. The right atrium
is moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload (? acute
pulmonary embolism vs. acute on chronic pulmonary hypertension).
The ascending aorta is mildly dilated. The aortic valve leaflets
are moderately thickened. There is moderate to severe aortic
valve stenosis (valve area 0.9 cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
[**2162-8-17**]: KUB IMPRESSION: Resolving SBO with normal gas pattern.
No evidence of obstruction or free air.
[**2162-8-18**]: KUB IMPRESSION: Findings worrisome for worsening ileus
vs partial or early full obstruction.
[**2162-8-19**]: KUB IMPRESSION: Improving bowel obstruction.
Brief Hospital Course:
83 year old woman with history of CAD s/p CABG, previous
diagnosis of UC, PMR on low dose prednisone, and atrial
tachycardia who was initially admitted to the Medicine service
with abdominal pain, found to have SBO with concern for Crohn's,
hospital course complicated by Afib with RVR with hypotension.
Her hospital course as follows by problems:
Partial SBO: Presented with obstructive symptoms and evidence of
narrowing of a 12-15 cm segment of the ileum on CT and MRE.
Initial concerns for infectious vs. inflammatory vs. ischemic
etiology; did not improve despite completely a course of
Cipro/Flagyl. Given history of UC, she was started on empiric IV
Solu-Medrol as the patient was not amenable to endoscopic
evaluation with sampling of this area. Her symptoms did not
improve the final read of MRE came back inconsistent with
Crohn's so her IV steroids were tapered down. She was kept NPO
except meds with decompression with an NGT until her NGT output
ceased; she continued to experience episodes of significant pain
despite remaining NPO. She was started on TPN. Single balloon
retrospective enteroscopy was planned for tissue biopsy for
diagnosis; however, the patient was unable to tolerate PO for
prep and was sent for surgical management. She was taken to the
operating room on [**2162-8-20**] for exploratory laparoscopy with lap
assisted small bowel resection. There were no complications.
Tissue for pathology was obtained; final path report revealed
neuroendocrine tumor. Postoperatively she remained on the TPN
that was started while on the Medicine service and also while
awaiting return of bowel function. Over the course of the next
several days post op she did have flatus and her NG was removed.
Sips were started slowly advancing to clears. Once able to
tolerate this she was advanced to solids but her appetite was
poor. Marinol was started with improvement in her overall
appetite. The TPN was then stopped and she is tolerating a
regular diet. Her staples will remain in place at time of
discharge and will need to be removed on [**2162-9-2**].
.
Afib with RVR: She has a h/o atrial tachycardia but no known AF
and was noted with unstable episode on the medical floor with
SBP 70 without any anginal symptoms to suggest acute coronary
syndrome. Her TSH was normal and LENI's were negative. Further
dropped to SBP 60 with beta blockade and was transferred to the
MICU. Dilt IV was effective at rate control. She remained
stable on metoprolol 5 mg IV q 6 hours after returning from the
MICU. Anticoagulation with warfarin was recommended by
cardiology; this is to be discussed after surgery. She was again
was noted with intermittent episodes of hypotension as low as 68
systolic and was orthostatic while working with PT. Her
Valsartan was being withheld for several doses based on hold
parameters and subsequently this was stopped. Once her blood
pressures stabilize this should be restarted. Her beta blocker
does was decreased initially until an episode on HD#20 she was
noted with Afib with RVR and was transferred to the ICU for a
short period of time. Her Lopressor was increased to 50mg tid
and her heart rates have ranged in the 90's. Anticoagulation was
recommended by Cardiology once able to take po's but the
decision was made to have her follow up with her PCP after
discharge from rehab for further evaluation of initiating this.
.
Hypoxia: Known right sided heart failure on nocturnal O2 that
was exacerbated by volume resuscitation .During her hospital
stay she required continuous oxygen therapy to maintain her
saturations >93%
Anemia: She was followed by Hematology during her stay who
recommended B12 and iron supplementation once taking po's.
Given her low hematocrit she was transfused with 1 unit packed
red cells. Post transfusion hematocrit was 27.6 and on day of
discharge it was 26.3.
Neuroendocrine tumor: Hematology/Oncology were consulted and it
is being recommended that she have serial follow up every three
months up until 1 yr. In the meantime an appointment has been
scheduled for her to follow up in their clinic after hospital
discharge.
Right sided heart failure: Diuretics and antihypertensives were
held initially given hypotension. Her home dose Lasix was
restarted and her electrolytes followed closely and repleted as
needed.
CAD: Known history, asymptomatic now, but troponin continues to
rise with change in morphology in V5 and V6. Serial EKG's were
followed and she was continued on an aspirin, beta blocker and
statin.
Complicated UTI: While on the medicine service she was treated
for a positive UA with ciprofloxacin 400 mg IV q12 hours.
Dispo: She was evaluated by Physical therapy and was recommended
for rehab after his acute hospital stay.
Medications on Admission:
Klor Con 20 mEq 1 packet [**Hospital1 **]
Tramadol-acetaminophen 37.5/325mg 1 tablet q4hrs prn
Diovan 80 mg po BID
Zolpidem 5 mg 1-2 tablets po qhs prn
prednisone 4 mg PO qday
prednisone 3 mg PO qhs
aspirin 81 mg PO qday
furosemide 80 mg po BID
pravastatin 20 mg po qhs
slow release iron 140 mg po qday
metoprolol tartrate 75 mg po qday
symbicort 160 mcg 4.5 mcg/actuation HFA inhlaer [**Hospital1 **]
Synthroid 75 mcg 1 tab po qday
OXYGEN 2L qhs and prn SOB
glucosamine chondroitin
perser vision
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Furosemide 80 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Tartrate 50 mg PO TID
6. Pravastatin 20 mg PO HS
7. PredniSONE 4 mg PO DAILY
8. PredniSONE 3 mg PO QHS
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Dronabinol 2.5 mg PO BID
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
12. Heparin 5000 UNIT SC TID
13. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION [**Hospital1 **]
14. FoLIC Acid 400 mcg PO DAILY
15. Ferrous Sulfate 45 mg PO DAILY
16. Vitamin D 800 UNIT PO DAILY
17. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral [**Hospital1 **]
18. traZODONE 100 mg PO HS:PRN insomnia
19. Senna 2 TAB PO HS
20. OxycoDONE (Immediate Release) 5-10 mg PO Q3H:PRN pain
21. Docusate Sodium 100 mg PO BID
22. Calcium Carbonate 500 mg PO QID:PRN indigestion
23. Pantoprazole 40 mg PO Q24H
24. Insulin SC
Sliding Scale
Fingerstick q6hrs
Insulin SC Sliding Scale using HUM Insulin
25. Simethicone 80 mg PO QID:PRN indigestion
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Small bowel obstruction
Ileal Neuroendocrine tumor
Malnutrition
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with an obstruction in your
intestines requring an operation to remove the blockage.
Biopsies of the intestinal tissue were taken at the time and you
were found to have a tumor that will need further evalution by
the Hematology/Oncology doctors.
You required a blood transfusion for anemia during your hospital
stay.
You were also evaluated by the Physical therapy team and being
recommended for rehab after your hospital stay.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2162-9-21**] at 2:00 PM
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] in the ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2162-9-22**] at 8:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2162-8-30**]
|
[
"263.9",
"441.4",
"414.00",
"209.43",
"427.31",
"560.89",
"285.1",
"401.9",
"V58.65",
"599.0",
"276.51",
"276.8",
"V46.2",
"556.9",
"560.1",
"244.9",
"272.4",
"V85.23",
"V45.81",
"458.0",
"997.49",
"725",
"E878.6",
"416.8",
"V12.55",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.21",
"38.91",
"45.62",
"99.15",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
15684, 15774
|
9317, 14057
|
317, 394
|
15906, 15906
|
4073, 9294
|
16570, 17306
|
3363, 3389
|
14604, 15661
|
15795, 15885
|
14083, 14581
|
16082, 16547
|
3404, 3409
|
262, 279
|
422, 2233
|
3423, 4054
|
15921, 16058
|
2255, 3237
|
3253, 3347
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,481
| 143,054
|
51853
|
Discharge summary
|
report
|
Admission Date: [**2101-9-1**] [**Month/Day/Year **] Date: [**2101-11-1**]
Date of Birth: [**2033-8-28**] Sex: F
Service: SURGERY
Allergies:
Codeine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Ventral hernia repair
Major Surgical or Invasive Procedure:
Ventral hernia repair
Left abdominal wall hematoma washout
Washout and drainage for an enterocutaneous fistula
Incision and drainage of an abdominal wall abscess
History of Present Illness:
68-year-old female who was transferred to the [**Hospital1 771**] approximately 18 months prior to this
admission. The patient had undergone exploratory laparotomy and
lysis of adhesions in a referring hospital. The patient was
transferred to [**Hospital1 **] with a complicated
intra-abdominal abscess and wound infection. Over the ensuing
months, the patient had developed a very complex ventral hernia
which had become increasingly symptomatic and now presents for
elective
repair.
Past Medical History:
SBO s/p surgery complicated by ventral heria repair and wound
infection requiring vancomycin and pigtail placement in [**Month (only) **]
[**2100**]; s/p hysterectomy, s/p lap chole, s/p LOA, epilepsy,
anxiety, tremors, depression, hypothyroid, sz d/o
Family History:
Noncontributory
Physical Exam:
Upon admission:
T 102.8 HR 120 BP 122/63 RESP 24 SAT 94% O2 2L
GENERAL: patient in acute distress, well nourished
HEENT:mucous membrane moist
Neck:IV access in the right side of the neck
CV:regular, normal S1/S2
Chest: clear to auscultation bilaterally
Abd:with drains form the surgical procedure. Limited exam.
Ext:well perfused
NEUROLOGICAL EXAMINATION:
Mental status: Awake, not responsive to verbal commands.
non-verbal. Moaning sounds, non intelligible word was
pronounced.
Cranial Nerves: Fundoscopic not performed. Pupils equally round
3mm and mild reactive to light bilaterally. Visual fields
difficult to assess, patient presented blink to threatening.
Persistent gaze eye deviation to the right, possible to break
with doll-eye maneuver. No nystagmus. corneal palpebral reflex
positive bilaterally. Facial movement symmetric. Palate
elevation
symmetric. Positive gag reflex. Tongue midline.
Motor: Normal bulk and tone bilaterally. Mild sporadic
multifocal
shaking episodes were observed, no asterixis, and no tremor. No
spontaneous movement of the four limbs were noted. Strength
antigravity in the lower extremities.
Sensation: responded with withdraw to noxious stimuli (triple
flexion??).
Reflexes: 2+ in the right side and 3 in the left side. Toes in
the middle bilaterally.
Coordination: not tested
Pertinent Results:
[**2101-9-2**] 07:30AM BLOOD WBC-18.1*# RBC-4.09* Hgb-11.3* Hct-32.8*
MCV-80* MCH-27.6 MCHC-34.4 RDW-13.0 Plt Ct-186
[**2101-9-2**] 07:30AM BLOOD Plt Ct-186
[**2101-9-2**] 07:30AM BLOOD Glucose-153* UreaN-7 Creat-0.7 Na-139
K-3.8 Cl-103 HCO3-27 AnGap-13
[**2101-9-2**] 07:30AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.5*
ECHO
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically
ventilated. Cannot assess RA pressure.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Resting tachycardia (HR>100bpm).
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function.
[**2101-10-29**]
CHEST, SINGLE VIEW
FINDINGS: There is a new right subclavian PICC line with tip in
the SVC. The left IJ line has been removed. There are small
bilateral effusions, right greater than left, with no focal
infiltrate.
Brief Hospital Course:
68 yo with large ventral hernia secondary to multiple abdominal
surgeries for SBO, who was admitted on [**2101-9-1**] for hernia
repair. Repair was performed as scheduled on [**9-1**], including
lysis of adhesions and placement of a bioprosthetic mesh.
Antibiotics were given peri-operatively, and post-op patient
extubated and without apparent immediate complications. She
became febrile starting on POD 1, no focal complaints except for
abdominal pain. She had a R IJ placed on [**9-4**]. She was noted to
have worsening mental status changes over [**Date range (1) 102894**], requiring
transfer to ICU on [**9-4**].
Since then, patient had continued to be febrile, tachycardic,
and with increasing WBC concern for sepsis. All cultures were
negative with LP negative for infection, EEG negative for
seizure activity but with evidence of encephalopathy.
Previous history of miscarriages and this sepsis of unclear
cause raised the possibility of stroke from septic emboli or
hypercoagulability state. Head CT was negative for embolic
events and hemorrhage. R IJ Catheter was removed on [**9-7**] after
it was noted that she had right UE swelling. Although an initial
Doppler US was negative for DVT, a repeat study on [**9-9**] after
concern for increasing right UE swelling showed a nonocclusive
thrombus in the right IJ and subclavian veins.
With persistent fevers and rising WBC on [**9-7**], LLQ incision was
opened by surgery at bedside and 200 cc hematoma evacuated,
wound VAC placed over incision.
Over the course of the next few days fevers persisted and
leukocytosis worsened so she was taken to the OR on [**9-12**] for
repeat washout, irrigation and debridement, but no abscess or
sources of infection was noted. Two days later her wound broke
down and she underwent an exploration with control of the
enterocutaneous fistula with mesh placement. Postoperatively
she was admitted to the intensive care unit. On [**9-16**] pt was
noted to be improving, but developed a non-occlusive thrombosis
of the right internal jugular and subclavian veins on heparin
but sub therapeutic PTT. She was continued on heparin with goal
of improving PTT. Pt also had a follow-up CT scan on [**9-18**]
which was suggestive of an abscess in the abdominal wall on the
left. She was taken back to surgery where an abscess was
identified and drained.
From [**9-18**] to [**10-13**] her SICU course was complicated by fevers,
work-ups and treatment for sepsis with negative CT scans for
intraabdominal abscesses. She also had worsening of liver and
respiratory function which led to the placement of a
tracheostomy tube and feeding tube and discontinuation of her
parenteral nutrition. Wound VAC over her midline and left
lateral wounds continued to be changed regularly with output
noted to be bilious at times. Wounds continued to improve with
no signs of infection.
On [**10-13**] she was transferred out of the ICU and continued to
improve clinically. On [**10-19**] she was noted to be febrile with
episodes of emesis and was worked up for source of infection.
Exams suggested a RLL consolidation with a positive blood
culture. She was restarted back on antibiotics and improved
clinically; they were continued for 2 weeks.
Her hematocrits intermittently dropped requiring transfusions
with packed red cells. She is known to have a chronic anemia
with ranges in hematocrit between 20-25. Her last blood
transfusion was on [**10-25**].
She was noted with increased leakage from around her G-tube
site, a tube study was performed under fluoroscopy which showed
normally positioned feeding tube with a small amount of
retrograde passing contrast. Given this it was felt that because
of the reflux her tube feeding rate was decreased where it had
previously been at goal.
Her psychiatric medications were restarted given her long
standing mental health issues with depression and anxiety.
She was evaluated by Physical and Occupational therapy and has
been recommended for acute rehab after her hospital stay.
Medications on Admission:
Oxycodone-Acetaminophen [Percocet] 5 mg-325 mg Tablet q4-6 hrs
prn
Ascorbic Acid [Vitamin C]
Aspirin 81 mg Tablet, Chewable
Calcium Carbonate [Calcium 600] 600 mg (1,500 mg) Tablet
Omega-3 Fatty Acids [Fish Oil]
Vitamin E
Seroquel
Valium
Celexa
Wellbutrin
remeron
[**Month/Day (2) **] Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day): Via J tube.
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours): via J tube.
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed: Via J tube.
10. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Via J tube.
11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) dose Intravenous Q8H (every 8 hours) for 4 days.
12. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
dose Intravenous Q24H (every 24 hours) for 4 days.
13. Primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Via J tube.
14. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) dose
Injection Q8H (every 8 hours) as needed.
15. Levothyroxine 200 mcg Recon Soln Sig: One (1) Recon Soln
Injection DAILY (Daily).
16. Levetiracetam 500 mg/5 mL Solution Sig: One (1) dose
Intravenous [**Hospital1 **] (2 times a day).
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
19. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
20. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection Before Breakfast and Dinner as needed: Per sliding
scale.
21. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
22. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
[**Location (un) **] Diagnosis:
Major Diagnoses:
Ventral henia repair complication by hematoma
Abdominal wall abscess
Enterocutaneous fistula
Pneumonia/Infection
Secondary:
Anxiety
Depression
Hypothyroid
Seizure disorder
[**Location (un) **] Condition:
Hemodynamically stable
[**Location (un) **] Instructions:
.
Followup Instructions:
Follow up with Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. in 2 weeks, call
[**Telephone/Fax (1) 600**] to schedule an appointment.
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab. It is being recommended that you have Test for Factor V
Leiden done. This can be arranged by your PCP.
Completed by:[**2101-11-6**]
|
[
"518.81",
"519.19",
"008.45",
"276.8",
"568.0",
"782.4",
"038.9",
"995.91",
"285.1",
"998.59",
"998.31",
"401.9",
"553.21",
"584.5",
"998.6",
"349.82",
"345.90",
"296.80",
"300.4",
"576.8",
"424.0",
"E878.8",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.07",
"54.3",
"96.72",
"99.15",
"33.22",
"99.04",
"54.12",
"53.61",
"33.24",
"54.0",
"39.95",
"86.22",
"38.95",
"03.31",
"99.77",
"38.93",
"31.1",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
5138, 9158
|
323, 487
|
2670, 5115
|
12105, 12519
|
1293, 1310
|
9184, 11660
|
1325, 1327
|
11794, 11986
|
262, 285
|
12018, 12043
|
11690, 11762
|
12078, 12082
|
515, 1002
|
1824, 2651
|
1341, 1683
|
1698, 1808
|
1024, 1277
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,807
| 149,065
|
4572
|
Discharge summary
|
report
|
Admission Date: [**2176-4-12**] Discharge Date: [**2176-4-30**]
Date of Birth: [**2109-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ibuprofen / Indocin
Attending:[**First Name3 (LF) 1162**]
Chief Complaint:
fever, altered mental status, hypoxia
Major Surgical or Invasive Procedure:
Intubation/Extubation
R PICC placement
History of Present Illness:
This is a 66 year old female who was brought in from her nursing
home with fever and altered mental status. History limited and
is obtained primary from the chart. Yesterday she was reportedly
noted to be lethargic and febrile to 103, and had a cough and
congestion. She was given tylenol and a dose of vancomycin. This
morning she remained febrile to 104 and continued to have
altered mental status (reportedly she is A+Ox3 at baseline). O2
sat was noted to be 88% on RA. She was brought by EMS to the ED.
.
In the ED, VS: 102.1, 96, 126/50, 97% on 2L nc initially.
However, her BP then dropped and she became less responsive. She
was intubated (for decreased mental status and
sepsis/hypotension), a RIJ line was placed, and she was started
on levophed for hypotension. She also received a total of 6L NS
and 1 unit PRBC. She was given doses of vancomycin, levaquin,
and cefepime. UA was positive, and CXR showed multilobar pna.
She is admitted to the MICU for sepsis.
Past Medical History:
COPD
DM
HTN
hypothyroidism
atypical CP
schizophrenia
RBBB
decubitus ulcers
constipation
OA
obesity
s/p R hemiarthroplasty 6 months ago, bed-bound since
Social History:
Nursing home resident since fall and R hemiarthroplasty 6 months
ago with rapid decline in functional status. Legal guardian is
[**Name (NI) **] [**Name (NI) **] (contact info below).
Family History:
unknown
Physical Exam:
Admission PE:
VS: 102.4, 104, 73/41, 24, 100%
VENT: AC at 550x14, PEEP 5, FiO2 100%
GENERAL: Intubated, awake, nods/shakes head to questions.
HEENT: PERRL, ETT and OGT in place.
CV: RRR, no m/r/g.
LUNGS: Coarse BS b/l, no wheezes.
ABD: hypoactive BS, obese, soft, NT/ND.
BACK: 3 decubitus ulcers. One central over coccyx, 2cm wide with
necrotic center. Two <1cm diameter but much deeper, ?probe to
bone, likely communicating together, with pus from deep swab.
EXTREM: 2+ DP pulses. B/l pressure ulcers on heels.
.
Discharge PE:
Afebrile breathing comfortably on RA
Obese woman in NAD. Alert and oriented to person and place,
occasionally date. Pleasant. Can make conversation though gets
easily distracted. Has tardive dyskinesia of tongue, jaw. Unable
to move legs/toes.
LUNGS: Coarse BS b/l, no wheezes.
ABD: + BS, obese, soft, NT/ND. Foley in place.
BACK: 3 decubitus ulcers. One central over coccyx, 2cm wide with
necrotic center. Two <1cm diameter but much deeper, ?probe to
bone, likely communicating together.
EXTREM: 2+ DP pulses. B/l pressure ulcers on heels. 2+edema b/l
LE's, some edema in UE's.
Pertinent Results:
d/c labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2176-4-30**] 06:03AM 7.2 3.10* 8.4* 27.0* 87 27.1 31.1 16.1*
391
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2176-4-30**] 06:03AM 61* 13 0.7 144 5.1 112* 25 12
.
Rest of labs:
[**2176-4-12**] 09:30AM BLOOD WBC-14.4*# RBC-3.22* Hgb-8.2*# Hct-28.4*#
MCV-88 MCH-25.5*# MCHC-28.8*# RDW-14.3 Plt Ct-612*#
[**2176-4-12**] 09:30AM BLOOD Neuts-82.2* Lymphs-14.8* Monos-2.0
Eos-0.8 Baso-0.2
[**2176-4-15**] 01:07AM BLOOD WBC-9.1 RBC-3.34* Hgb-9.1* Hct-29.1*
MCV-87 MCH-27.2 MCHC-31.2 RDW-15.5 Plt Ct-286
[**2176-4-26**] 05:37AM BLOOD WBC-8.1 RBC-3.17* Hgb-8.6* Hct-27.4*
MCV-86 MCH-27.2 MCHC-31.5 RDW-16.2* Plt Ct-435
[**2176-4-26**] 05:37AM BLOOD Neuts-67.3 Lymphs-26.7 Monos-3.0 Eos-2.7
Baso-0.3
[**2176-4-12**] 09:30AM BLOOD PT-15.3* PTT-26.9 INR(PT)-1.4*
[**2176-4-16**] 05:08AM BLOOD PT-12.8 PTT-28.1 INR(PT)-1.1
[**2176-4-12**] 09:30AM BLOOD Glucose-172* UreaN-77* Creat-1.4* Na-152*
K-5.3* Cl-117* HCO3-22 AnGap-18
[**2176-4-12**] 02:50PM BLOOD Glucose-224* UreaN-65* Creat-1.2* Na-149*
K-4.6 Cl-120* HCO3-18* AnGap-16
[**2176-4-13**] 03:04AM BLOOD Glucose-220* UreaN-55* Creat-0.9 Na-147*
K-4.7 Cl-122* HCO3-18* AnGap-12
[**2176-4-25**] 05:53AM BLOOD Glucose-90 UreaN-16 Creat-0.5 Na-144
K-4.5 Cl-114* HCO3-25 AnGap-10
[**2176-4-26**] 05:37AM BLOOD Glucose-61* UreaN-14 Creat-0.6 Na-143
K-4.6 Cl-113* HCO3-27 AnGap-8
[**2176-4-12**] 09:30AM BLOOD ALT-12 AST-15 CK(CPK)-37 AlkPhos-39
Amylase-19
[**2176-4-14**] 02:34AM BLOOD ALT-11 AST-16 LD(LDH)-167 AlkPhos-45
TotBili-0.2
[**2176-4-12**] 09:30AM BLOOD cTropnT-0.28*
[**2176-4-12**] 02:50PM BLOOD CK(CPK)-65
[**2176-4-12**] 02:50PM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2176-4-13**] 03:04AM BLOOD CK(CPK)-102
[**2176-4-13**] 03:04AM BLOOD CK-MB-4 cTropnT-0.16*
[**2176-4-25**] 05:53AM BLOOD Albumin-2.1* Calcium-8.1* Phos-3.6 Mg-1.8
[**2176-4-14**] 02:34AM BLOOD Albumin-2.4* Calcium-7.9* Phos-2.1*
Mg-1.9
[**2176-4-12**] 09:30AM BLOOD Albumin-2.7*
[**2176-4-25**] 05:53AM BLOOD VitB12-566
[**2176-4-22**] 11:43PM BLOOD Ammonia-15
[**2176-4-18**] 03:19PM BLOOD Ammonia-88*
[**2176-4-16**] 05:08AM BLOOD TSH-0.84
[**2176-4-16**] 05:08AM BLOOD Free T4-0.70*
[**2176-4-12**] 11:30PM BLOOD Cortsol-27.7*
[**2176-4-12**] 11:00PM BLOOD Cortsol-27.1*
[**2176-4-12**] 10:12PM BLOOD Cortsol-22.6*
[**2176-4-22**] 05:34AM BLOOD Vanco-12.8
[**2176-4-20**] 06:05AM BLOOD Vanco-18.1
[**2176-4-19**] 11:53AM BLOOD Vanco-16.2
[**2176-4-18**] 06:04AM BLOOD Vanco-32.7*
[**2176-4-17**] 09:29PM BLOOD Vanco-38.0*
[**2176-4-17**] 06:37AM BLOOD Vanco-42.5*
[**2176-4-17**] 02:16AM BLOOD Valproa-38*
[**2176-4-16**] 05:08AM BLOOD Valproa-40*
[**2176-4-15**] 12:16PM BLOOD Type-ART pO2-155* pCO2-39 pH-7.29*
calTCO2-20* Base XS--6
[**2176-4-15**] 01:24AM BLOOD Type-ART pO2-108* pCO2-48* pH-7.26*
calTCO2-23 Base XS--5
[**2176-4-14**] 12:06PM BLOOD Type-ART pO2-117* pCO2-43 pH-7.24*
calTCO2-19* Base XS--8
[**2176-4-12**] 03:36PM BLOOD Type-MIX pO2-68* pCO2-44 pH-7.26*
calTCO2-21 Base XS--6
[**2176-4-12**] 09:35AM BLOOD Lactate-1.6
[**2176-4-14**] 06:14AM BLOOD Lactate-1.4
[**2176-4-12**] 03:02PM BLOOD freeCa-1.10*
CLOZAPINE
Test Result Reference
Range/Units
NORCLOZAPINE 108 25-400 NG/ML
REFERENCE RANGE FOR NORCLOZAPINE:
25-400 NG/ML (TROUGH, STEADY STATE)
TOXIC RANGE: NOT WELL ESTABLISHED.
Test Result Reference
Range/Units
CLOZAPINE 363 NG/ML
REFERENCE RANGE FOR CLOZAPINE:
THE THERAPEUTIC RESPONSE BEGINS TO APPEAR AT
100 NG/ML. REFRACTORY SCHIZOPHRENIA APPEARS TO
REQUIRE A THERAPEUTIC CONCENTRATION OF AT LEAST
350 NG/ML (TROUGH, AT STEADY STATE).
TOXIC RANGE: GREATER THAN 1000 NG/ML
TEST PERFORMED AT:
[**Company **] [**Doctor Last Name **] INSTITUTE
[**Numeric Identifier 14272**] P.0. BOX [**Numeric Identifier 19430**]
CHANTILLY, [**Numeric Identifier 19431**]
Comment: Source: Line-cl
.
[**2176-4-28**] STOOL C.DIFF- NEGATIVE
[**2176-4-21**] URINE URINE CULTURE-FINAL {YEAST} 10-100,000 colonies
[**2176-4-20**] CATHETER TIP-IV WOUND CULTURE-FINAL INPATIENT
NEGATIVE
[**2176-4-19**] URINE URINE CULTURE-FINAL {YEAST} 10-100,000 colonies
[**2176-4-19**] BLOOD CULTURE Blood Culture, Routine-FINAL INEG
[**2176-4-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT***
[**2176-4-15**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL No
VRE isolated.
[**2176-4-15**] BLOOD CULTURE Blood Culture, Routine-NEG INPATIENT
[**2176-4-14**] BLOOD CULTURE Blood Culture, Routine-NEG INPATIENT
[**2176-4-14**] BLOOD CULTURE Blood Culture, Routine-NEG INPATIENT
[**2176-4-13**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL -NEGATIVE
[**2176-4-13**] SPUTUM GRAM STAIN (Final [**2176-4-13**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2176-4-15**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. HEAVY GROWTH.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2176-4-12**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT
[**2176-4-12**] [**2176-4-12**] 9:35 am BLOOD CULTURE 2ND SET/VENIPUNCTURE.
Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM
ONE SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2176-4-13**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2176-4-12**] URINE CULTURE (Final [**2176-4-15**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2176-4-12**] BLOOD CULTURE Blood Culture, Routine-NEG
.
EKG: NSR at 94bpm, RBBB, no apparent ischemic changes. No prior
for comparison.
.
CXR at NH: slight RLL and modest LLL infiltrates
.
CXR [**2176-4-12**]: Multifocal, patchy air-space opacities likely
representing multifocal pneumonia.
.
CHEST (PORTABLE AP) Study Date of [**2176-4-17**] 4:44 AM
HISTORY: Pneumonia, status post extubation, to evaluate for
change.
FINDINGS: In comparison with the study of [**4-16**], the endotracheal
and
nasogastric tubes have been removed. Streak of atelectasis in
the left mid lung zone persists. Again, the area behind the
heart is difficult to evaluate, and the possibility of
atelectasis or even pneumonia cannot be excluded. IMPRESSION:
Little change except for ET and NG tube removal.
.
[**2176-4-17**] CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 19432**] HISTORY: NG tube
placement. FINDINGS: In comparison with earlier study of this
date, there has been placement of a nasogastric tube that
extends well into the stomach. There is increasing opacification
in the left hemithorax consistent with increasing pleural fluid
and probable consolidation.
.
[**2176-4-19**] CHEST (PORTABLE AP) In comparison with study of [**4-17**], the
opacification in the left mid lung zone appears to be decreasing
with the consolidative appearance giving way to more atelectatic
change. The left hemidiaphragm is more sharply seen, though some
blunting would still be consistent with effusion. Catheters
remain in place.
.
TTE [**2176-4-15**]: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%) The
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. No
pathologic valvular flow identified.
.
SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING [**2176-4-25**] 10:49
AM
FINDINGS: There is no evidence of metallic foreign body within
the orbits. There is an irregular lucency within the frontal
skull appreciated on the anteroposterior view. Please correlate
clinically.
There is a right-sided PICC line with the tip at the superior
vena cava. There is increased opacity within the left lung
compared to the right, likely in keeping with airspace disease.
Within the abdomen there are multiple dilated loops of small
bowel, predominantly within the right upper and lower quadrants.
There are multilevel degenerative changes within the lumbosacral
spine. There is a bipolar total hip arthroplasty in place.
IMPRESSION: No evidence of metallic foreign body within the
orbits. Status post bipolar total hip arthroplasty on the left.
Increased opacity within the left lung likely related to
airspace disease from an infectious process such as pneumonia.
Please correlate clinically.
Brief Hospital Course:
66 year old woman with multiple medical problems who presented
with fever, hypoxia, and altered mental status, secondary to
sepsis, admitted initially to the MICU, then when extubated and
hemodynamically stable was transferred to the floors [**4-17**] for
futher management.
.
MICU Course: She was continued on vanc/cefepime/cipro. She
received IVF boluses and was continued on levophed and
eventually dobutamine to maintain pressures. These were weaned
by [**2176-4-15**]. She was also given high dose hydrocortisone (100mg IV
q8h) for adrenal insuffuciency and this was weaned off as well.
She defervesced on [**2176-4-13**] and urine grew klebsiella so she was
continued on cefepime (for 14 day course) and cipro was d/c'd on
[**4-16**] based on sensitivities. Sputum grew coag+staph and she was
continued on vanc/cefepime for 7 day course for PNA. Psych was
consulted re: schizophrenia meds and initally recommended
continuing home medications, and checking daily WBC/diff to
monitor for agranulocytosis given clozapine. She was extubated
on [**2176-4-16**]. OG tube was d/c'd but given that the patient remained
delerious NGT was placed and tubefeeds were restarted before
transfer to the floors.
.
Remaining hospital course by problem:
.
1) AMS/weakness: The patient had AMS on transfer to the floor.
She was delerious after extubation, likely from a combination of
infection and hypernatremia (see below), and was somnolent. A
head CT was obtained and was negative for bleed or evidence of
increased ICP. After resolution of hypernatremia, the patient
became more alert but was noted to have some memory problems and
word-finding difficulties and poor concentration. She was also
noted to have generalized weakness, with inability to move toes
or legs, and ability to lift arms about [**2-16**] of the way off the
bed with shakiness and difficulty and inability to squeeze hand.
Neurology was consulted and her PCP and other health care
providers were contact[**Name (NI) **] to ascertain her baseline MS and
strength. According to her PCP her weakness seems to have been a
rapidly progressive process likely from deconditioning which has
occurred over the last 6 months as the patient has been
bed-bound x6months since her R hemiarthroplasty. Neurology
agreed this could be from deconditioning but given how profound
her weakness was they were concerned for another brain or spinal
cord pathology and recommended MRI of brain and spine.
Excerpt from their assessment: "Diffusely weak and in particular
with severe LE weakness. Pattern is difficult to assess due to
obesity, edema, variable effort (encephalopathy). Spasticity
suggests UMN component, but hyporeflexia in legs suggests
LMN/peripheral. To account for UE and LE weakness requires
C-spine or brain lesions, but given that LE weakness is so much
more prominent and exam is difficult, T-L spine lesion also must
be excluded. Agree with need for C-T spine MRI and also L-spine
MRI. Also brain MRI to r/o infarcts (e.g. watershed from
hypoperfusion when septic/hypotensive). Duration of illness may
not be long enough for ICU neuropathy or ICU myopathy, but EMG
also can help to localize the weakness if peripheral (nerve vs
NMJ vs muscle)."
Unfortunately the patient was not able to tolerate the MRIs
(attempted twice), even with mild sedation with ativan, due to
anxiety. It was decided MRI would be deferred, and the patient
can follow up with neurology as an outpatient (see appointment
scheduke) after attempting more intensive physical therapy in
rehab. Overall her MS appeared back to baseline and her memory
problems appeared to resolve by the time of discharge. She still
has profound lower extremity weakness, but can move the toes of
her L foot. She can lift her arms about [**2-14**] way up off bed. She
will need intensive rehab.
.
2) Edema: The patient was grossly volume overloaded when
transferred to the floors. This was felt to be likely from
stasis/inactivity. The patient has a normal EF on TTE. Given
concern for AMS and electrolyte imbalance (hypernatremia),
diuresis was deferred for a few days but began on [**4-25**] as her MS
improved. She was given prn lasix 20mg IV with goal negative 1
to 1.5 L per day, which was achieved. She is still grossly
overloaded and is being discharged on 20mg po lasix. Her volume
status/weight/ ins and outs should be monitored daily and her
lasix adjusted accordingly. At last once weekly Chem7 should be
checked for monitoring.
.
3) Schizophrenia: The patient has a history of schizophrenia.
She has baseline tardive dyskinesia (gyrating tongue and jaw).
Psych was consulted to help manage her medications. She was
continued on clozaril and daily WBC with diff was obtained
initially, with no sign of agranulocytosis. Her valproic acid
(pt was on for mania)and gabapentin were discontinued per psych
recs due to her altered MS as above and the patient tolerated
this change well. She should have a follow up appointment with
her outpatient psychiatrist arranged 1-2 weeks after discharge.
Clozapine level was checked and was within normal limits.
.
4) Sepsis: Patient presented initially as febrile, hypotensive,
with elevated WBC. Possible causes include pneumonia, UTI,
decubitus ulcers (see below). As noted in the MICU course
summary, the patient had septic physiology with a documented UTI
and pneumonia which was treated with Vanc(7 days)/Cefepime (14
days). She had defervesced on [**4-13**]. She mounted a fever again on
[**4-19**] with some increased sputum production but was
hemodynamically stable. Because she was at risk for aspiration
PNA due to her initially altered MS, she was started on flagyl
(in addition to vanc/cefepime). Her central line which had been
placed in the MICU was discontinued as well. Flagyl was
subsequently discontinued as her CXR did not suggest pneumonia
and the patient was clinically well. All blood cultures were
negative. Vanc was discontinued after blood cx's were negative
for 48hrs and she had completed a 7 day course for PNA.
Cefepime course of 14 days was completed on [**4-25**]. The patient
improved clinically and was back to baseline MS by [**4-27**]. No
cultures are pending currently.
.
5) Respiratory/pneumonia: The patient is status post extubation
on [**2176-4-16**], satting well on RA. She completed a 7 day course of
vanc/cefepime for staph aureus pneumonia as above.
.
6) UTI: klebsiella susceptible to cefepime. She completed a 14
day course of cefepime on [**4-25**]. Her foley was changed on [**4-20**] and
[**4-24**] due to cloudy urine. Her subsequent urine cultures were
suggestive of yeast colonization which was not treated.
.
7) Decubitus ulcers: The patient was noted to have several
ulcers, some of which may probe to bone. Plastic surgery was
consulted and followed, making the following assessment/recs:
*Right ear: 1 x 0.3 cm area of intact blistered erythema tissue
*Left heel: full thickness ulcer approx 4 x 4 cm with 70% reg
granular tissue, 30% black/ yellow necrotic tissue. I was able
to palpate bone. There is a large amount of serosang yellow
drainage with no odor. There are no s/s of cellulitis. *Left
great toe: intact reddened tissue 1 x 1 cm, no surrounding
edema. *Left ant ankle: improved with intact reddened tissue.
*Right lateral lower leg: full thickness ulcer 9 x 2.5 x 0.8 cm
with necrotic yellow/black wound bed. There is a large amount
of
serous yellow drainage with odor. The wound edges are
irregular. Medial to this there is another wound with less depth
approx. 7 x 2 cm, 70% red wound bed, 30% yellow slough. The
tissue around the right leg ulcers has less erythemia than seen
prior. *Right heel: full thickness ulcer approx. 7 x 6 x 0.5
cm, 75% red wound bed with 25% yellow tissue. Bone is palpable.
There is a large amount of yellow drainage with no mild odor.
The periwound tissue is intact with no s/s of infection.
*Coccyx: Stage IV pressure ulcer 4.5 x 3 cm with proximal area
of 2.5 x 2.4 x 2 cm, 60% yellow tissue/40% pink tissue. There
is another full thickness area of ulceration right gluteal with
4.5 x 2 x 6.5 cm with undermining from [**7-25**] o'clock approx. 5cm.
There is some necrotic tissue between the ulcers beneath the
skin
but close to interconnecting. The periwound tissue shows
improvement with less erythema, no induration, fluctance or
crepitus. *Left posterior thigh: 0.3 x 7 cm full thickness
ulcer that maybe related to trauma from catheter tubing. The
wound bed is 100% yellow with minimal serous drainage -no odor.
*Right posterior thigh: intact pink tissue 0.3 x 5 cm.
Goals of wound care: prevention of further tissue breakdown,
improvement in wounds
Recommendations: Continue Pressure relief per pressure ulcer
guidelines. See wound care instructions. Patient has plastics
follow up arranged in [**2-14**] weeks.
.
8) Hypernatremia: The patient was noted to be hypernatremic
shortly after being transferred from the MICU. This resolved
after free H20 boluses and IVFs. The patient appears total body
volume overloaded but had no extrinsic source of Na such as NS.
She could have had hypernatremia from mineralocorticoid excess
given she had recent high dose steroid injections in the MICU.
.
9) Diabetes: The patient was continue on 10u lantus qhs with
HISS. Her oral hypoglycemics were held while in hospital, can
consider restarting as an outpatient.
.
# Hypothyroid: She was continued on her home levothyroxine home
dose.
.
# PPx: SC heparin, PPI, bowel regimen
.
# Access: d/c'd RIJ, has R PICC, arm looked a little swollen,
had elevated and has improved
.
# FULL CODE (confirmed with guardian)
# Communication: Legal Guardian [**Name (NI) **] [**Name (NI) **] cell:
[**Telephone/Fax (1) 9990**]; home [**Telephone/Fax (1) 19433**]. PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19434**] [**Hospital1 2177**] pager
[**Telephone/Fax (1) 7799**] ID4[**Telephone/Fax (1) 19435**] office [**Telephone/Fax (1) 19436**].
Psychiatrist [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 19437**], Psych NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 19438**]
[**Telephone/Fax (1) 19439**]
.
Dispo: rehab
Medications on Admission:
-levothyroxine 125
-abilify 30 daily
-prilosec 20 daily
-furosemide 40 daily
-MVI
-depakote 2000mg hs
-neurontin 300mg hs
-clozapine 200mg hs
-topamax 25 hs
-colace 100 [**Hospital1 **]
-metformin 1000mg [**Hospital1 **]
-glipizide 10mg [**Hospital1 **]
-metoprolol 25 [**Hospital1 **]
-lidoderm patch (to left hip)
-tylenol 1000mg tid
-duoneb tid
-oxycodone q4h prn
-robitussin
-cipro 500mg daily x14 days (started [**4-2**])
-lantus 10u hs
Discharge Medications:
1. Influenza Tri-Split [**2175**] Vac 45 mcg/0.5 mL Suspension Sig:
One (1) ML Intramuscular ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Q8H (every 8 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed for SOB, wheezing.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
7. Aripiprazole 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Clozapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Topiramate 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
14. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
17. Insulin Lispro 100 unit/mL Cartridge Sig: as directed units
Subcutaneous as directed: check FS at brkfst, lunch,dinner, HS.
for glucose <60 4 oz juice; 61-150, 0 units; 151-200, 2 units;
201-250, 4 untis; 251-300, 6 untis; 301-350, 8 units; 351-400,
10 units; >400 [**Name8 (MD) 138**] MD.
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**]
Discharge Diagnosis:
Primary:
1. urinary tract infection
2. MRSA pneumonia
3. delerium
4. generalized weakness
5. schizofrenia
6. decubitus ulcers
7. anasarca
Secondary:
1. diabetes
2. hypothyroid
Discharge Condition:
Alert and oriented x3. Pleasant. Has baseline tardive
dyskinesia. Obese woman with b/l leg ulcers and decubitus
ulcers. Afebrile on room air. Able to wiggle L foot toes. Able
to lift arms [**2-14**] way up off bed.
Discharge Instructions:
You were admitted to the hospital because you had fever, altered
mental status and hypoxia. You were intubated for respiratory
failure and stayed in the ICU. You were treated with
antibiotics (2 weeks of cefepime and 7 days of vancomycin) for a
UTI and a pneumonia. You were extubated successfuly and
transferred to the medical floors for care. Psychiatry was
consulted and mananaged your psychiatruc medications. You
continued to be confused after extubation but your mental status
improved with time and you were fully alert and oriented by the
time of discharge. Your valproic acid and gabapentin were
discontinued. In addition, there was concern that you were
overall very weak. Neurology was consulted and felt that some of
this weakness may be due to your long period of being bed-ridden
(deconditioning). However, they recommended obtaining an MRI of
your brain and spine to rule out cord pathology or stroke.
Unfortunately you were not able to tolerate the MRI despite 2
attempts with calming medications, so this study was deferred.
It was recommended to follow up with neurology as an outpatient
to monitor strength and progress.
.
The following changes were made to your medications: Gabapentin
and valproic acid were discontinued. Your glipizide was held as
an inpatient this may be restarted in rehab. You were started on
20mg po lasix for diuresis you as you were total body grossly
overloaded as an inpatient. You also responded well to 20mg IV
lasix. You should have your creatinine and chem 7 checked at
least weekly for monitoring. You should be weighed daily and
your ins and outs should be monitored daily and volume status
assessed. Your doctor should adjust the lasix as needed to
optimize your volume status. It is hoped that decreased
extremity edema will assist you in making progress with your
re-conditioning goal.
.
Plastic surgery was consulted for management of your multiple
pressure ulcers and they debrided these and made recommendations
for wound care. Please follow the wound management
recommendations and go to your follow up appointment as below.
.
If you develop fever, chest pain, light headedness, shortness of
breath, altered mental status, worsening weakness or any other
concerning symptoms, please call your doctor or come to the
hospital.
Followup Instructions:
Neurology follow up appointment [**2176-5-15**] at 4pm with Dr. [**First Name (STitle) **] [**Name (STitle) **]
[**Telephone/Fax (1) 1942**], [**Hospital Ward Name 23**] building, [**Location (un) **]
.
Please go to follow up appointment with plastic surgery
regarding your multiple pressure ulcers [**2176-5-17**] at 1:30pm [**Hospital Ward Name 23**]
Clinical Center [**Hospital Ward Name 516**] [**Location (un) 470**] surgical specialties.
.
Please arrange follow up with PCP when discharged from rehab:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19434**] [**Hospital1 2177**] pager [**Telephone/Fax (1) 7799**] ID4[**Telephone/Fax (1) 19435**] office
[**Telephone/Fax (1) 19436**].
.
Please arrange follow up with outpatient psychiatrist:
Psychiatrist [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 19437**], Psych NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 19438**]
[**Telephone/Fax (1) 19439**] within 1-2 weeks.
Please arrange follow up with psychiatrist [**First Name8 (NamePattern2) 1059**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 19437**], Psych NP [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 19438**] [**Telephone/Fax (1) 19439**]
Completed by:[**2176-4-30**]
|
[
"518.81",
"250.02",
"785.52",
"707.05",
"496",
"348.30",
"599.0",
"482.41",
"V09.0",
"038.9",
"995.92",
"295.90",
"707.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
25304, 25408
|
12755, 13969
|
331, 372
|
25628, 25845
|
2920, 12732
|
28180, 29471
|
1766, 1775
|
23417, 25281
|
25429, 25607
|
22950, 23394
|
25869, 28157
|
1790, 2304
|
2318, 2901
|
254, 293
|
13997, 21318
|
21330, 22924
|
400, 1374
|
1396, 1549
|
1565, 1750
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,224
| 157,616
|
10845+10846
|
Discharge summary
|
report+report
|
Admission Date: [**2170-3-7**] Discharge Date: [**2170-3-12**]
Date of Birth: [**2101-12-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
cholecystectomy [**2170-3-9**]
History of Present Illness:
68 Yo male with Hep B, hx choledocholithiasis requiring ERCP
[**2165**] who presents with abdominal pain, jaundice and fever. Pt
reports onset on [**1-26**] severtiy dull pain during dinner(fish and
tofu) last night at 7pm. He noted onset of fever/chills shortly
after. He denies CP, SOB, n/v/d. He had normal BM this AM, no
blood. Pain is less severe than with his choledocholithiasis in
past. Pt denies itching of skin but did have dark urine. Pt said
pain subsided after 3-4 hours. He noted nothing that helped or
exacerbated the pain. He has no pain currently.
In ED he recieved IV fluids, levofloxacin, flagyl and ampicillin
Past Medical History:
[**2165**] Choledocholithiasis s/p ERCP and sphincterotomy with
resultant bleeding from papilla requiring EGD with epinephrine
injection to stop bleeding
- post-ERCP pancreatitis
HTN
high cholesterol
Type II DM
Hepatitis B
CRI 1.3-1.5
Social History:
retired, no ETOH, tobacco, drugs
Physical Exam:
VS; 100.0 84 123/75 16 96% RA
HEENT: EOMI, mildly icteric, mildly dry MM
Neck: supple, JVP not elevated, -lad
lungs: CTA bilat
heart: RRR nl s1 s2,
abd: soft ND, NABS + RUQ tenderness with + [**Doctor Last Name 515**] sign,
-guarding, rebound
ext: -edema
neuro: CN intact
skin: mild jaundice
Pertinent Results:
[**2170-3-6**] 09:45PM BLOOD WBC-12.8*# RBC-5.02 Hgb-15.4 Hct-45.4
MCV-91 MCH-30.8 MCHC-34.0 RDW-13.3 Plt Ct-172
[**2170-3-9**] 04:55AM BLOOD WBC-7.1 RBC-3.91* Hgb-12.0* Hct-35.6*
MCV-91 MCH-30.8 MCHC-33.8 RDW-13.6 Plt Ct-145*
[**2170-3-10**] 02:59AM BLOOD WBC-14.8*# RBC-2.96* Hgb-9.1* Hct-26.8*
MCV-91 MCH-30.8 MCHC-33.9 RDW-13.7 Plt Ct-153
[**2170-3-11**] 06:20AM BLOOD WBC-15.0* RBC-2.87* Hgb-8.8* Hct-25.9*
MCV-91 MCH-30.9 MCHC-34.1 RDW-13.6 Plt Ct-167
[**2170-3-12**] 05:12AM BLOOD WBC-10.7 RBC-2.71* Hgb-8.7* Hct-24.6*
MCV-91 MCH-31.9 MCHC-35.2* RDW-13.7 Plt Ct-223
[**2170-3-6**] 09:45PM BLOOD Neuts-87.0* Bands-0 Lymphs-7.9* Monos-4.0
Eos-0.7 Baso-0.4
[**2170-3-6**] 11:05PM BLOOD PT-13.7* PTT-27.2 INR(PT)-1.2*
[**2170-3-9**] 02:38PM BLOOD PT-12.5 PTT-30.0 INR(PT)-1.1
[**2170-3-6**] 09:45PM BLOOD Glucose-131* UreaN-21* Creat-1.7* Na-135
K-4.6 Cl-99 HCO3-23 AnGap-18
[**2170-3-12**] 05:12AM BLOOD Glucose-149* UreaN-21* Creat-1.3* Na-137
K-3.6 Cl-101 HCO3-26 AnGap-14
[**2170-3-6**] 09:45PM BLOOD ALT-1159* AST-649* LD(LDH)-396*
AlkPhos-115 Amylase-52 TotBili-6.0* DirBili-3.1* IndBili-2.9
[**2170-3-8**] 05:00AM BLOOD ALT-478* AST-127* LD(LDH)-143 AlkPhos-114
Amylase-62 TotBili-4.4* DirBili-3.1* IndBili-1.3
[**2170-3-10**] 02:59AM BLOOD ALT-228* AST-120* LD(LDH)-144 CK(CPK)-73
AlkPhos-78 Amylase-23 TotBili-1.3
[**2170-3-12**] 05:12AM BLOOD ALT-147* AST-40 AlkPhos-72 Amylase-58
TotBili-1.3
[**2170-3-6**] 09:45PM BLOOD Lipase-25
[**2170-3-10**] 02:59AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-3-10**] 09:45PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2170-3-6**] 09:45PM BLOOD Albumin-4.4 Calcium-9.4 Phos-3.7 Mg-1.9
[**2170-3-11**] 06:20AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.2* Mg-1.8
[**2170-3-12**] 05:12AM BLOOD Albumin-2.9* Calcium-8.1* Phos-3.6 Mg-2.0
[**2170-3-6**] 09:45PM BLOOD HBsAg-POSITIVE HBsAb-NEGATIVE
HBcAb-POSITIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2170-3-8**] 05:00AM BLOOD AFP-1.0
[**2170-3-6**] 09:45PM BLOOD Acetmnp-NEG
[**2170-3-6**] 09:45PM BLOOD HCV Ab-NEGATIVE
.
RUQ u/s [**3-6**]: IMPRESSION:
1. Moderately distended gallbladder containing a tiny non-mobile
stone in the gallbladder neck. No evidence of gallbladder wall
thickening or pericholecystic fluid. Although there is no
evidence of acute cholecystitis by ultrasound, given the
distended gallbladder, if there is a high clinical concern for
early cholecystitis or gallbladder dyskinesia, a HIDA
examination may be helpful.
2. No evidence of hepatic mass or intrahepatic ductal
dilatation.
.
ERCP [**3-7**]: FINDINGS: Retrograde cholangiogram during ERCP
demonstrates filling defects in the common bile duct consistent
with choledocholithiasis. Remainder of the biliary tree appears
normal. No radiologist was present during the procedure.
.
CXR [**3-8**]: IMPRESSION: No acute cardiopulmonary process. Possible
right upper lobe pulmonary nodule for which further evaluation
with chest CT is suggested.
.
Chest CT [**3-9**]: IMPRESSION:
1. Small inflammatory opacity, right upper lobe, does not
require further follow up.
2. Small prevascular mediastinal mass. Enlarged lymph node or
thymoma should be considered. Further followup chest CT in three
months recommended.
3. Bilateral, nonobstructing renal calculi.
4. Probable Zenker's diverticulum.
.
[**3-7**] Blood cx 1/4 bottles: ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
68 YO M with hepatitis B, hx choledocholithiasis s/p ERCP with
schincterototmy who presented with RUQ abd pain, fever, elevated
LFT. ERCP was performed showing choledocholithiasis. Patient's
abdominal pain had resolved even prior to ERCP. Tranaminitis
and hyperbilirubinemia improved. Hepatitides labs c/w chronic
hep B infection, viral load pending. Past Hep A infection, no
evidence of Hep C infection. AFP negative, EBV and CMV pending.
Given that this was second episode, recommended cholecystectomy.
Patient transferred to surgery service for surgery.
.
ID - initial blood cx's from admission with 1/4 bottles with
e.coli pan sensitive, presumable from biliary source. Pt
discharged on levofloxacin.
.
Hep B - pt states he has a hx of chronic Hep B carrier status
since [**2143**], he has never required treatment. Hep B Viral load
pending, follow-up as outpatient.
.
Renal insufficiency - Cr stable
.
DM - controlled with ISS
.
Hypercholesterolemia - held statin given transaminitis
Medications on Admission:
pt does not no names of his BP, cholesterol and DM meds
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while taking pain medication.
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for PRN.
Disp:*30 Tablet(s)* Refills:*0*
3. Medications
Resume taking all pre-hospital medications as before
4. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
cholangitis/choledocolithiasis
htn
DM
Discharge Condition:
Stable
Discharge Instructions:
Call Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 673**] if fevers, chills, nausea,
vomiting, abdominal pain, redness/bleeding or pus from incision.
No heavy lifting
[**Month (only) 116**] shower
Followup Instructions:
Test for consideration post-discharge: Hepatitis Be Antigen
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2170-3-26**] 11:00
Completed by:[**2170-3-14**] Admission Date: [**2170-3-7**] Discharge Date: [**2170-3-12**]
Date of Birth: [**2101-12-24**] Sex: M
Service: [**Last Name (un) **]
ADDENDUM: The patient was initially admitted to the medical
service under Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] and patient was transferred to
the surgical service to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
CHIEF COMPLAINT: Rule out cholangitis, evaluation for
cholecystectomy.
HISTORY OF PRESENT ILLNESS: Patient was a 68-year-old male
Cantonese speaking who presented with 2 day history of right
upper quadrant pain with associated chills and fever,
positive jaundice, no emesis, no nausea. Pain onset was
shortly after eating fatty meal the prior evening. The
patient presented with some pain, but slightly improved.
History of choledochocholelithiasis, status post ERCP on [**2166-4-19**] complicated by upper GI at site of sphincterotomy.
Patient with known periampullary diverticulum. GI service was
consulted and surgical consult was requested. Patient was
hemodynamically stable in the ER.
PAST MEDICAL HISTORY: As noted above, hepatitis B,
hypertension, diabetes and increased cholesterol.
PAST SURGICAL HISTORY: As above. Upper GI bleed after an EGD
on [**2166-4-19**].
ALLERGIES: No known drug allergies.
HOSPITAL COURSE: Patient was given levo and Flagyl in the
ED. This was continued. Hepatitis panel was obtained and a
hepatology consult was obtained for preop eval for
cholecystectomy. Patient was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. No
stigmata of chronic liver disease was noted. No palmar
erythema. Impression was of hep B. Recommendations included
proceeding with cholecystectomy as there was no clinical or
radiological evidence of cirrhosis and liver biopsy was
recommended intraop. Patient was preoped, taken to the OR by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2170-3-9**]. Patient underwent a
laparoscopic cholecystectomy with liver biopsy. Preoperative
diagnosis was choledocholithiasis. Postop diagnosis the same.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] assisted. EBL was minimal. No apparent
complications were noted. Please see operative report for
further details. The patient was started on a Dilaudid PCA in
the PACU. Patient was a bit tachy postoperatively. He was
given LR boluses of 500 cc 5 times. He received a total of
4450 of Crystalloid. Urine output was initially low and this
picked up after the bolusing. He received a total of 1 liter.
Hematocrit was 33.6. repeat hematocrit was 35, hemoglobin
11.7. Returned back to the medical surgical unit in stable
condition. He was extubated in the PACU. He was encouraged to
use the PCA Dilaudid for pain. Patient experienced minimal
pain. His diet was advanced. Abdomen appeared minimally
distended and nontender. Pain was well controlled. Urine
output was improved with fluid resuscitation. Hematocrit
ranged between 35, dropped down to 27 with a total of 4
liters of IV Crystalloid. His LFTs trended down. He
experienced a temperature of 101.1. Blood and urine cultures
were drawn. Blood cultures were subsequently negative. Urine
culture was negative as well. Of note a hep B viral load was
less then 60 IU/ML performed by PCR. Patient's abdominal
laparoscopic chole sites were clean, dry and intact. His diet
continued to be advanced and he remained on IV Levaquin and
Flagyl. His lungs were clear. Foley was removed and he was
able to void independently. Patient was tolerating a regular
diet. His metformin was restarted and he was switched to po
Levaquin and Flagyl. Vital signs were stable. He was
ambulatory and safe for discharge. He was discharged home on
[**3-12**].
DISCHARGE MEDICATIONS: Colace 100 mg po b.i.d., Percocet
5/325 mg tabs 1 to 2 tabs po p.r.n. every 4 hours, Levaquin
500 mg po every day for 10 days, Flagyl was discontinued.
DISCHARGE DIAGNOSES: Cholangitis, choledochocholelithiasis,
hypertension and diabetes.
He is scheduled to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2170-3-26**]. He was to resume all prehospital medications.
[**Name6 (MD) **] [**Name8 (MD) **], NP
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2170-3-21**] 10:37:15
T: [**2170-3-21**] 11:42:24
Job#: [**Job Number 35358**]
|
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icd9cm
|
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,819
| 175,944
|
1922
|
Discharge summary
|
report
|
Admission Date: [**2149-8-23**] Discharge Date: [**2149-9-12**]
Date of Birth: [**2087-8-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Left leg angiography
History of Present Illness:
Mr [**Known lastname **] is a 62 y/o man with PMH notable for s/p renal pancreas
tx, 4-5 days of vomiting with abdominal pain and bloody
diarrhea, fevers (didnt take temp), chills, no ill contacts,
recent travel to [**Name (NI) 1727**] for windjammer (?) trip within past month
but no other travel. He drove himself (the evening of [**8-22**]) to
[**Location (un) **]-wellsely where he was noted to be initially hypotensive
to 94/66 HR 64 resp 20 sat 100% RA, temp 94.9 rectal. He was
given total 2L NS, 4mg iv morphine, 4mg iv zofran and zosyn
3.375gm iv. Abdominal pain mostly over tx pancreas. Temp there
94 initially, placed on bear hugger, temp improved to 97.3 po by
time of transfer. He was ordered for ct abd/pelvis (not sure if
that was done) but had US that prelim showed tx pancreas in rlq,
appears adematous with associated peripancreatic fluid
suggesting pancreatitis, GB mildly distended with dilatation in
common bile duct 8mm, native kidneys atrophic, spleen normal, tx
kidney and left lower quadrant reportedly nl but doppler flow
not done. WBC 20, hct 49.7, plt 311, diff 90 pmn, <10 bands, 7
lymph, [**Doctor First Name **] 1265, lip 3709, albumin 4.6, bicarb <10.
In the ED: initial vitals were: T 98.5 rectal, HR 67, BP 107/50,
RR 20, 100% on RA. He was given 3L NS, D5W with 3 amps bicarb
x1L, solumedrol 500mg iv, solucort 100mg iv, zofran 4mg iv,
prograf 2mg iv, and dilaudid 1mg iv. US of abdomen repeated.
On arrival to the ICU he is sleepy and confused (does not know
where he is or why he is here). He c/o HA, mild photophobia,
meningismus, abdominal pain, no current fevers or chills.
Past Medical History:
* Liver/kidney transplant 10 years ago
* type 1 DM s/p SPK in [**2138**]
- complicated by neuropathy, nephropathy (cr 1.9)
* per his sister, has had difficulty with left foot vascular
supply recently and was referred by his pcp but details unknown
* Hypertension
* Hypercholesterolemia
* s/p esophagectomy in [**2145**] for Barrett's vs esophageal cancer
* h/o TIA
* h/o perineal abscess in [**2147**]
* s/p appy age 11
* h/o R foot Staph infection, reportedly no osteo
* OSA
* Gastroparesis
Social History:
1.5ppd x15yrs quit [**2135**]. Retired. Divorced, no kids. Rare
alcohol, denies drug use.
Family History:
N/C
Physical Exam:
VS: T 97.5 BP 142/111 P 76 RR 11 O2sat 99RA
Gen: A&Ox3, NAD
HEENT: No scleral icterus, MM slightly dry
Heart: RRR, no m/r/g
Lungs: Distant BS bilat with mild bibasilar rales
Abdomen: NABS. Soft, nondistended. Very TTP over RLQ transplant
site with no rebound or guarding. Also with mild RUQ and LLQ
tenderness.
Ext: LLE cool to touch, no palpable DP or PT pulses. Other ext
WWP with 2+ pulses. No edema. No sensation of bilat feet, but
intact on bilat shins.
Pertinent Results:
[**2149-8-23**] 07:00AM BLOOD WBC-17.9* RBC-5.40# Hgb-15.2# Hct-48.7#
MCV-90 MCH-28.2 MCHC-31.2 RDW-14.1 Plt Ct-263#
[**2149-8-23**] 07:00AM BLOOD Neuts-92.5* Lymphs-4.9* Monos-2.3 Eos-0.3
Baso-0.1
[**2149-8-23**] 01:44PM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2*
[**2149-8-23**] 07:00AM BLOOD Glucose-118* UreaN-84* Creat-4.2*# Na-136
K-5.1 Cl-111* HCO3-9* AnGap-21*
[**2149-8-23**] 01:44PM BLOOD ALT-6 AST-8 LD(LDH)-160 CK(CPK)-34*
AlkPhos-135* Amylase-1115* TotBili-0.3
[**2149-8-23**] 07:00AM BLOOD Lipase-4650*
[**2149-8-23**] 07:00AM BLOOD Calcium-9.3 Phos-5.4*# Mg-1.9
[**2149-8-23**] 07:32AM BLOOD tacroFK-7.8
[**2149-8-23**] 07:06AM BLOOD Lactate-1.0
[**2149-8-23**] 07:32AM BLOOD %HbA1c-5.5
[**2149-8-23**] 01:44PM BLOOD Triglyc-196* HDL-12 CHOL/HD-8.8
LDLcalc-55
Abdominal U/S [**8-23**]:
IMPRESSION:
1. Elevated resistive indices in the transplanted kidney within
the left
lower quadrant. This is a nonspecific finding, and can be seen
with chronic
rejection or infection.
2. No hydronephrosis or perinephric fluid collection involving
the
transplanted kidney.
3. Mildly dilated common bile duct, similar in appearance from
[**2148-5-30**]
CT, allowing for differences in modality. If clinically
indicated, this can
be further evaluated with an MRCP.
Lower ext arterial duplex U/S [**8-25**]:
IMPRESSION:
1. Severe flow deficit to the left foot.
2. Normal right ABI.
Pancreas U/S [**8-26**]:
IMPRESSION:
1. Unremarkable appearance of the pancreas transplant, with
preserved flow
throughout.
2. Disorganization and heterogeneity of tissues deep to the left
lower
quadrant kidney transplant, new from the prior study. This
raises the
possibility of a hematoma at this locale, which is not affecting
the kidney in terms of hydronephrosis or mass effect at this
time. A short-term followup scan is advised.
Lower ext vein mapping U/S [**8-26**]:
IMPRESSION: The greater saphenous veins are widely patent
bilaterally, there is minimal focal dilatation at the popliteal
level and the distal calf on the right as well as the popliteal
level and at the level of the ankle on the left.
CXR PA/Lat Preop [**8-26**]:
Mild atelectatic changes are seen at the left base though there
is no evidence of acute pneumonia. Right IJ catheter extends to
the lower portion of the SVC.
Angiogram [**8-29**]:
____________________.
Femoral vascular U/S [**8-29**]:
IMPRESSION: No pseudoaneurysm or fistula.
Brief Hospital Course:
1) Pancreatitis: Patient is s/p pancreas transplant (bladder
anastamosis). APACHE II using patient's initial labs was 26,
which has a roughly 57% mortality. Pancreas U/S at OSH
consistent with acute pancreatitis. Given the coexisting renal
failure, and low urine amylase compared with prior, this was
concerning for graft rejection. CMV serology and viral load were
negative. Unable to biopsy the kidney to assess rejection due to
his heparin drip (see below). He was initially admitted to the
ICU due to altered mental status and a R IJ central line was
placed for administration of anti-thymocyte globulin. His mental
status improved and he was transferred to the floor. The central
line was kept due to inability to obtain reliable peripheral
access, as well as concern for bleeding if removed due to the
heparin drip. He received ___ doses of anti-thymocyte globulin,
as well as __ doses of 500mg IV methylprednisolone, then 1 dose
of 100mg IV methylprednisolone. The latter was converted to
prednisone 40mg x2 days, then 20mg daily. He was also
aggressively volume resuscitated with IV fluids. Over the first
few days, his pain significantly improved, and his diet was
advanced to regular, which was well tolerated. Pancreas U/S at
[**Hospital1 18**] showed resolution of inflammation, and his amylase and
lipase trended down. His tacrolimus was slowly increased to ___
due to lower levels, likely due to holding his calcium channel
blocker. He was also started on valganciclovir and TMP/SMX
prophylaxis. Note that the repeat pancreas U/S showed a possible
hematoma associated with the transplanted kidney. This should be
reassessed with a follow up study.
2) Acute on chronic renal failure: Creatinine was initially 4.2,
while baseline from [**3-10**] was 1.6. Prerenal as well as ATN
suspected, likely ischemic, given muddy brown casts in urine and
patient presented with hypotension. IV fluid resuscitated as
above, with bicarb-containing fluids. His creatinine decreased
to ___ by discharge.
3) Peripheral arterial disease: Coolness of the left foot was
noted while in the ICU, therefore a heparin drip was started and
ASA was resumed. Per patient's sister, this problem may have a
chronic component. Arterial duplex U/S showed no flow in the
left foot. Vein mapping for bypass showed widely patent greater
saphenous veins. He had a left LE angiogram with pre-procedure
hydration with bicarb and mucomyst. The angiogram showed
popliteal occlusion below the knee. Post-cath check on day of
angiogram showed bilateral femoral bruits, although U/S of the
entry site showed no aneurysm or fistula. The foot remained cool
on exam, but without evidence of necrosis.
4) Nongap metabolic acidosis: Initially had an increased gap,
now closed. Likely due to diarrhea on admission that was
self-limited, as well as NS hydration, bicarb loss from pancreas
graft, and renal failure. Bicarb improved with IV fluids
containing bicarb.
5) HTN: Metoprolol increased to 50mg TID with good control.
Calcium channel blocker was held.
On [**2149-9-8**] patient underwent a left above-knee popliteal to
peroneal bypass with
non reverse saphenous vein graft, angioscopy. Post-operative
course was essentially unremarkable.
Neuro: The patient received morphine and oxycodone with good
effect and adequate pain control. When tolerating oral intake,
the patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
diltiazem 240 daily
aspirin 325mg daily
atenolol 100mg daily
prednisone 4mg daily
cellcept 1 gm [**Hospital1 **]
prograf 2mg qam, 1mg qpm
botox yearly injection for gastroparesis
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Complete blood count, Chem 10, tacrolimus level to be drawn
every 2 weeks
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis, Acute on chronic renal failure, below knee
popliteal artery occlusion
Discharge Condition:
Improved
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-5**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and [**Month/Day (3) **] dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
You were found to be iron deficient and anemic you should have
an outpt. colonoscopy to evaluate for polyps.
You also had a low B12 level with anemia, you recieved a vitamin
B12 supplement shot while in the hospital, you should see your
primary care physician to determine if you continue to need
vitamin B12 shots.
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-10-16**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2149-10-9**] 9:45
Completed by:[**2149-9-12**]
|
[
"E878.0",
"V15.81",
"V12.54",
"E932.0",
"280.9",
"V42.0",
"276.50",
"252.00",
"281.1",
"403.90",
"327.23",
"275.3",
"996.86",
"787.91",
"585.9",
"440.22",
"584.5",
"577.0",
"276.51",
"593.81",
"276.2",
"249.00",
"272.4",
"V10.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"39.29",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11958, 11964
|
5554, 10291
|
329, 351
|
12098, 12109
|
3133, 5531
|
14969, 15604
|
2634, 2639
|
10520, 11935
|
11985, 12077
|
10317, 10497
|
12133, 14536
|
14562, 14946
|
2654, 3114
|
275, 291
|
379, 1996
|
2018, 2511
|
2527, 2618
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,337
| 112,766
|
22250
|
Discharge summary
|
report
|
Admission Date: [**2189-5-26**] Discharge Date: [**2189-5-28**]
Date of Birth: [**2134-8-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
post liver biopsy bleed
Major Surgical or Invasive Procedure:
sp liver biopsy [**2189-5-26**]
History of Present Illness:
54 yo w/ h/o HC cirrhosis s/p OLT [**2-4**]. s/p scheduled biopsy
4/26 per hepatitis LT protocol. Incidentally had mild
tranaminitis. After biosy complained of nausea. HCT from 31 to
28 to 24. Admitted for transfusion and monitoring.
Past Medical History:
HEP C (tatoos); Grade III esophageal varices; CCY; HTN; RFA of
hepatocellular CA; Repair of ruptured cervical disc
Social History:
multiple tatoos
Physical Exam:
Afebrile HR 80's, bp 127/82
NAD A&OX3
RRR
CTAB
Soft, NT/ND
biopsy site-C/D/I, no hematoma
warm, well perfused, +2 DP/PT
Pertinent Results:
[**2189-5-26**] 10:30AM BLOOD WBC-2.4* RBC-3.55* Hgb-10.8* Hct-31.4*
MCV-88 MCH-30.5 MCHC-34.5 RDW-14.0 Plt Ct-86*
[**2189-5-26**] 01:15PM BLOOD WBC-2.9* RBC-3.19* Hgb-9.6* Hct-28.2*
MCV-88 MCH-30.0 MCHC-34.0 RDW-13.9 Plt Ct-104*
[**2189-5-26**] 03:13PM BLOOD WBC-3.7* RBC-2.71* Hgb-8.3* Hct-24.3*
MCV-90 MCH-30.6 MCHC-34.1 RDW-14.0 Plt Ct-103*
[**2189-5-26**] 04:27PM BLOOD WBC-3.6* RBC-2.77* Hgb-8.2* Hct-24.4*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.6 Plt Ct-82*
[**2189-5-26**] 05:42PM BLOOD Hct-31.5*#
[**2189-5-27**] 12:34PM BLOOD Hct-33.3*
[**2189-5-27**] 03:38PM BLOOD Hct-33.4*
[**2189-5-28**] 12:29AM BLOOD Hct-32.8*
[**2189-5-28**] 08:34AM BLOOD Hct-32.8*
[**2189-5-26**] 10:30AM BLOOD Glucose-93 UreaN-14 Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-26 AnGap-13
[**2189-5-28**] 04:05AM BLOOD Glucose-107* UreaN-7 Creat-0.7 Na-140
K-3.4 Cl-110* HCO3-25 AnGap-8
[**2189-5-26**] 10:30AM BLOOD ALT-82* AST-78* AlkPhos-120* TotBili-0.4
[**2189-5-28**] 04:05AM BLOOD ALT-46* AST-37 AlkPhos-87 TotBili-0.4
[**2189-5-26**] 10:30AM BLOOD rapamycin-TEST
[**2189-5-27**] 07:50AM BLOOD rapamycin-TEST
Brief Hospital Course:
Pt was admitted to the ICU for serial monitoring, exams and Hct.
The pt was transfused prn and Hct had remained stble for > 24
hrs prior to DC.
A CT abdomen was obtained upon admission [**5-26**] and revealed the
following:
Medium-attenuation fluid in the abdomen and pelvis consistent
with hemorrhage mixed with peritoneal fluid. Higher attenuation
blood at the 9th, 10th rib interspace on the right consistent
with the site of hemorrhage. It is uncertain if the hemorrhage
originates from the hepatic parenchyma or an intercostal vessel.
No active extravasation from the liver is observed.
The pt was without complaints throughout the hospital course.
The pt spiked a fever to 101.9 on HD2. A fever work-up was
obtained and was negative upon DC. It was presumed that the
fever was secondary to the bleed. Upon DC, the pt was afebrile
for almost 24 hours.
Preliminary biopsy results were obtained and were as follows:
recurrent HCV, no evidence of rejection.
The pt was DC's to home on HD3 and was to follow up at the
transplant clinic per the coordinator's instructions.
Medications on Admission:
Cellcept, Bactrim, Protonix, Calium, Lopressor, Lasix, [**Last Name (un) 1380**],
Pravachol
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Insulin Regular Human 100 unit/mL Solution Sig: Five (5) mg
Injection ASDIR (AS DIRECTED).
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
post liver biopsy bleed [**2189-5-26**]
Discharge Condition:
stable
Discharge Instructions:
Please call physician if experiencing fever/chills,
nausea/vomiting, dizziness/visual changes, or
questions/concerns. Resume pre-procedure medications. [**Last Name (un) 1380**]
level/biopsy results pending.
Please call physician if experiencing fever/chills,
nausea/vomiting, dizziness/visual changes, or
questions/concerns. Resume pre-procedure medications. [**Last Name (un) 1380**]
level/biopsy results pending.
Followup Instructions:
Follow up as per instructed by transplant coordinator.
[**Last Name (un) 1380**] level/biopsy results pending.
Completed by:[**2189-5-28**]
|
[
"E878.0",
"285.1",
"070.70",
"998.11",
"E878.8",
"996.82",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
3926, 3932
|
2069, 3152
|
338, 372
|
4016, 4024
|
961, 2046
|
4492, 4635
|
3294, 3903
|
3953, 3995
|
3178, 3271
|
4048, 4469
|
821, 942
|
275, 300
|
400, 635
|
657, 773
|
789, 806
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,975
| 166,101
|
31103
|
Discharge summary
|
report
|
Admission Date: [**2105-8-12**] Discharge Date: [**2105-8-13**]
Date of Birth: [**2053-5-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52yo M on plavix/ASA/coumadin for MI/stent, was assaulted
last night. + ETOH. No LOC. Transfered from OSH for CT finding
of
SDH. INR at OSH was 1.0. Denied rhinorrhea/otorrhea or salty
taste in throat.
Past Medical History:
MI and s/p stent 2 months ago. was on plavix/ASA/coumadin,
although patient's INR OSH and here is NL.
Social History:
Lives alone at home. Denied smoking/illegal drug use. Stats
occasionally drink beers. (Note: EtOH, Opiates, and Cocaine in
urine on admission)
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T: 97 120/85 65 18 100% O2sat on 4L
Gen: swelling/bruise left eyelid; neg rhinorrhea/otorrhea. L arm
on sling due to L SHD AC separation.
HEENT: Pupils: PERRLA EOMs ful
Neck: on c-collar; slight point tenderness mid-cervical.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake, cooperative with exam.
Orientation: Oriented to person, place, and date.
Language: Speech slow with good comprehension and repetition.
Naming intact. No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5mm to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal right side, unable
to test left due to SHD injury.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-16**] RUE/RLE/LLE, normal left
bicep/tricep/grip. proximal LUE unable to assess due to L SHD
injury.
Sensation: Intact to light touch bilaterally.
Reflexes: [**2-15**] throughout.
Toes downgoing bilaterally
Coordination: slight atxic of right arm on finger-nose-finger,
Nl
heel to shin.
Pertinent Results:
Repeat Head CT prior to Discharge:
Unchanged appearance of small-to-moderate right-sided subdural
hematoma
layering over the right tentorium and thin vertex right
parafalcine subdural hematoma.
Head CT on Admission to ED:
Small-to-moderate subdural hematoma layering over the right
tentorium, and
thin right vertex parafalcine subdural hematoma, with no
significant mass
effect or shift of midline structures.
Shoulder XRAY AP/LAT:
IMPRESSION: Findings consistent with Grade III
acromioclavicular separation. No glenohumeral abnormality.
[**2105-8-12**] 06:11AM GLUCOSE-90 UREA N-23* CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14 CALCIUM-9.0
PHOSPHATE-4.2 MAGNESIUM-2.4
[**2105-8-12**] 06:11AM CK(CPK)-220*
[**2105-8-12**] 06:11AM cTropnT-<0.01
[**2105-8-12**] 06:11AM WBC-9.9 RBC-4.15* HGB-13.8* HCT-39.0* MCV-94
MCH-33.2* MCHC-35.3* RDW-13.4 PLT COUNT-243
[**2105-8-12**] 06:11AM PT-12.4 PTT-24.7 INR(PT)-1.1
[**2105-8-12**] 04:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
Brief Hospital Course:
The pt. is a 52 y/o male on Plavix, aspirin, and Coumadin s/p
recent MI stent placement who was admitted from the ED on [**2105-8-12**]
after assaulting his girlfriend and then being assualted himself
by his landlord. Pt. recieved a head CT at OSH with a finding
of a R tentorial SDH. The pt. was recoagulated there and
transferred to [**Hospital1 18**]. His INR on presention in the ED was 1.0.
He was admitted to the TSICU at [**Hospital1 18**] for observation, repeat
head CT, evaluation by Orthopedics for L shoulder pain, and
medication with anti-convulsants.
Repeat Head CT scan at [**Hospital1 18**] was positive for a Right tentorial
subdural hematoma. This SDH was managed conservatively with
monitoring and a repeat Head CT. AP films of his left shoulder
revealed a Grade III glenhumoral separation. This was managed
with pain medicaion and his left arm was subsequently placed in
a sling.
The patient had an uneventful hospital course with steady
improvement over his 2 day stay. There were no acute events
during his stay. At the time of discharge, the patient was
afebrile, tolerating a regular diet, at full activity with good
pain control by PO medication, and denied any visual changes,
headache, and was neurologically intact.
Medications on Admission:
1. Plavix
2. ASA
3. Warfarin
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*168 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: You
may restart on [**2105-8-15**].
3. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: You
may restart on [**2105-8-15**].
Discharge Disposition:
Home
Discharge Diagnosis:
Right Tentorial Subdural Hematoma
Discharge Condition:
Stable
Discharge Instructions:
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc. You may restart your aspirin and Plavix on [**2105-8-15**]
?????? Take Dilantin as prescribed and follow up with laboratory
blood drawing as ordered. Take Dilantin until your follow up
appointment
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
Dr.[**Last Name (STitle) **] TO BE SEEN IN [**6-19**] WEEKS. YOU WILL NEED A CAT SCAN OF
THE BRAIN WITH THIS VISIT
|
[
"414.01",
"852.21",
"E968.9",
"V58.61",
"V45.82",
"831.04",
"291.81",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5124, 5130
|
3452, 4708
|
337, 343
|
5207, 5215
|
2364, 3429
|
6372, 6560
|
878, 882
|
4787, 5101
|
5151, 5186
|
4734, 4764
|
5239, 6349
|
912, 1254
|
280, 299
|
371, 575
|
1458, 2345
|
1269, 1442
|
597, 701
|
717, 862
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,684
| 144,766
|
7810
|
Discharge summary
|
report
|
Admission Date: [**2188-9-11**] Discharge Date: [**2188-9-20**]
Date of Birth: [**2156-12-9**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
diarrhea, abdominal pain
Major Surgical or Invasive Procedure:
TEE, external pacemaker implantation.
History of Present Illness:
Mr. [**Known lastname **] is s 31 yo M with PMH of HIV/AIDS (CD4= 34, not on
HAART), Hep B + C, and ESRD on HD who presents from dialysis
with fever and abdominal pain x 3 days.
He reports 2-3 days of watery, non-bloody diarrhea up to five
times a day. He has had some abdominal pain and nausea, but no
vomiting. He c/o some stomach cramps such that he stopped eating
food but he did keep drinking fluids. +thirsty. He does not make
any urine at baseline. He has had a dry throat but no cough. He
describes headaches that come and go as well as some mild
photophobia, which is baseline for him.
He went to HD today, and was noted to be hypotensive to 80/50
and febrile 101.3. He was then referred to the ED; no dialysis
was done.
In the ED, VS: 100.5 90 90/49 16 100%RA. Tmax in ED was 101.3
and lowest SBP (by report, not recorded), was 63. Abdomen was
tender in LUQ. Guaiac negative. Labs were notable for lactate of
0.6, no leukocytosis. EKG with TWI in V2-V3, but no ischemic
changes. CXR revealed no acute process. Given hypotension, a
quick bedside US of chest was performed, which showed no
pericardial effusion. 3L NS administered, and BP improved to
100s. A CT abdomen was obtained which showed thickening of
descending colon. Blood cultures were drawn, and he received
levo and flagyl, as well as tylenol and ASA. He was then
admitted to the ICU. Renal evaluated the patient and did not
think there was an indication for urgent dialysis. Most recent
vitals 95.1 57 100/56 17 100%RA.
Past Medical History:
- HIV dx'd [**2172**], currently not on HAART due to intolerance, h/o
PCP [**Last Name (NamePattern4) **] [**12-25**]
- Coag negative staph endocardiits s/p MVR and AVR in [**1-25**], s/p
vanc x 4 weeks
- HCV + but has no detectable circulating virus
- HBV + but HBc equivocal [**10/2186**]
- ESRD [**1-19**] HIV Nephropathy on HD (though pt reports it was from
HTN), s/p LUE AVF revision [**4-24**], [**5-25**].
- Secondary hyperparathyroidism [**1-19**] ESRD
- Chronic LBP; seen in pain clinic; told secondary to OA/nerve
impingement
- Asthma
Social History:
Lives with his mother. Smokes 1PPD x > 20 years. Per chart, used
IV drugs as teen, though patient currently denies ever using.
Family History:
Family History:
- Father: Hypertension/Diabetes [**Month/Day (2) **]
- No family hx of kidney disease
Physical Exam:
VS 94.8 58 92/60 13 100% RA Weight on bed is 71kg.
Gen: Pleasant, NAD, lying comfortably in bed.
Eyes: right eye is somewhat larger than left but both are
reactive to light
ENT: Face symmetric, small amount of thrush lining tongue and
inner cheek
Neck: Supple, no jvd
CV: RRR, [**3-23**] SM heard throughout precordium
Resp: Good air movement with some small wheezes throughout as
well as squeeks.
Abd: +BS, soft, minimal generalized tenderness, nondistended, no
rebound, liver edge smooth and felt 2cm below costal margin
Ext: LUE AV fistula with thrill. No edema, good peripheral
pulses, no cyanosis
Neuro: A&OX3
Skin: warm, no rashes
Psych: appropriate
Pertinent Results:
Admission Labs:
[**2188-9-11**] 07:03PM GLUCOSE-85 UREA N-39* CREAT-9.4* SODIUM-131*
POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-28 ANION GAP-15
[**2188-9-11**] 07:03PM CK(CPK)-27* ALK PHOS-351*
[**2188-9-11**] 07:03PM CK-MB-NotDone cTropnT-0.15*
[**2188-9-11**] 07:03PM CALCIUM-8.2* PHOSPHATE-4.6* MAGNESIUM-1.7
[**2188-9-11**] 07:03PM WBC-4.1 RBC-3.22* HGB-10.0* HCT-30.3* MCV-94
MCH-31.0 MCHC-33.0 RDW-16.8*
[**2188-9-11**] 07:03PM NEUTS-80.3* LYMPHS-15.3* MONOS-3.6 EOS-0.6
BASOS-0.3
[**2188-9-11**] 07:03PM PLT COUNT-100*
[**2188-9-11**] 07:03PM PT-18.2* PTT-32.0 INR(PT)-1.7*
[**2188-9-11**] 10:27AM LACTATE-0.6
[**2188-9-11**] 08:25AM GLUCOSE-90 UREA N-36* CREAT-9.6*# SODIUM-131*
POTASSIUM-4.1 CHLORIDE-89* TOTAL CO2-30 ANION GAP-16
[**2188-9-11**] 08:25AM ALT(SGPT)-9 AST(SGOT)-21 CK(CPK)-26* ALK
PHOS-412* TOT BILI-0.7
[**2188-9-11**] 08:25AM LIPASE-15
[**2188-9-11**] 08:25AM CK-MB-2 cTropnT-0.15*
[**2188-9-11**] 08:25AM WBC-5.4 RBC-3.02* HGB-9.4* HCT-28.2* MCV-94
MCH-31.2 MCHC-33.4 RDW-16.9*
[**2188-9-11**] 08:25AM NEUTS-78.6* LYMPHS-15.9* MONOS-5.1 EOS-0.2
BASOS-0.1
[**2188-9-11**] 08:25AM PLT COUNT-107*
[**2188-9-11**] 08:25AM PT-16.6* PTT-31.3 INR(PT)-1.5*
Discharge Labs:
[**2188-9-20**] 06:55AM WBC-4.6 RBC-3.16* Hgb-9.9* Hct-30.1* MCV-95
MCH-31.2 MCHC-32.8 RDW-17.9* Plt Ct-174
[**2188-9-20**] 06:55AM PT-14.6* PTT-29.0 INR(PT)-1.3*
[**2188-9-20**] 06:55AM Glucose-76 UreaN-17 Creat-7.2*# Na-136 K-3.9
Cl-98 HCO3-29
[**2188-9-20**] 06:55AM Calcium-8.0* Phos-3.2 Mg-1.9
[**2188-9-20**] 06:55AM Vanco-10.7
Studies:
[**2188-9-11**] EKG: Sinus rhythm. Prolonged P-R interval. Compared to
the previous tracing no change.
[**2188-9-11**] CXR - The patient is status post median sternotomy. The
cardiomediastinal silhouette is stable. There are no areas of
consolidation. The visualized bones appear unremarkable. The
previously seen ground glass opacities have resolved.
CONCLUSION: No acute cardiopulmonary process.
[**2188-9-11**] CT abd and pelvis with contrast - CONCLUSION:
1. Stable hepatosplenomegaly without any focal lesions.
2. Mild thickening of the wall of distal descending and sigmoid
colon may be infectious or inflammatory.
3. Atrophic small kidneys with maximum craniocaudal measurement
of 7 cm.
4. Right basal effusion along with atelectasis.
[**2188-9-12**] ECHO: The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 40 cm from the incisors. A bioprosthetic aortic valve
prosthesis is present. The posterior aortic root is thickened
but no definite abscess is idenfitied. Trivial intraaortic
valvular regurgitation is seen. No masses or vegetations are
seen on the bioprosthetic aortic valve. A bioprosthetic mitral
valve prosthesis is present. A paravalvular mitral prosthesis
leak is present. No mass or vegetation is seen on the mitral
valve. Moderate (2+) mitral regurgitation is seen. No vegetation
or mass is seen on the tricuspid or pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No mass or vegetation is seen on the bioprosthetic
mitral and aortic valves. There is abnormal thickening of the
posterior aortic root without any definitive abscess seen.
Moderate paravalvular mitral regurgitation.
[**2188-9-12**] MR [**Name13 (STitle) 430**] without contrast IMPRESSION:
1. Severely limited study shows no acute intracranial process.
2. Diffusely low marrow signal, consistent with marrow
hyperplasia, which
could be secondary to anemia or HIV.
[**2188-9-12**] Left upper extremity doppler - IMPRESSION: No evidence
of septic thrombus in the fistula.
[**2188-9-12**] CXR - FINDINGS: Endotracheal tube has been placed
terminating 3.8 cm above carina. Worsening bibasilar opacities,
probably pulmonary edema and less likely aspiration, with
adjacent bilateral small pleural effusions.
[**2188-9-13**] ECG - Sinus rhythm. A-V conduction delay. Compared to
the previous tracing of [**2188-9-12**] the T wave abnormalities
recorded on [**2188-9-12**] are more prominent, now with T wave
inversions in lead V3. Followup and clinical correlation are
suggested.
[**2188-9-18**] CT T & L spine - final read still pending. Discussed
with radiologist and no abscess seen.
Brief Hospital Course:
31 year old gentleman with h/o HIV not on HAART, ESRD on HD, and
h/o coag neg Staph endocarditis s/p MVR/AVR [**1-25**] admitted with
fevers and diarrhea, found to have Strep Viridans endocarditis.
# Strep viridans endocarditis: The patient is immunocompromised
and has a history of endocarditis. The pt had a recent admission
in [**7-/2188**] with similar symptoms. The initial differential for
his fevers was broad and included persistent low grade
endocarditis (supported by a new PR prolongation on EKG), CMV
colitis, viral gastroenteritis, C diff colitis, or [**Doctor First Name **]. He
responded appropriately to volume challenge and his blood
pressures were been stable in 90s/50s upon presentation to the
MICU. A TTE on [**9-12**] demonstrated "mod-to-severe paravalvular
mitral regurgitation without definite vegetations seen, but the
new finding of paravalvular mitral regurgitation is consistent
with acute infectious endocarditis." There was also concern for
CNS process given headaches and unequal pupils on exam, although
clinical presentation did not suggest bacterial meningitis. Of
note, LP done [**7-/2188**] was negative. CXR did not show infiltrate.
In the ICU the pt received vancomycin and gentamicin (50mg) and
was continued on flagyl given evidence of colitis. His white
count was 5,000 without bands, a CXR showed no evidence of
pneumonia or heart failure, an abdominal CT showed mild
thickening of the wall of distal descending and sigmoid colon.
The patient grew GPC in [**3-23**] blood cultures later found to be
Strep viridans. The patient was intubated to undergo TEE which
demonstrated (details above) tricuspid valve vegetation with
mild tricuspid regurgitation, a thickened region of posterior
aortic root consistent with probable abscess and mild to
moderate central mitral regurgitation and (at least) moderate
eccentric paravalvular leak.
CT surgery was consulted, and they did not feel that the patient
was a surgical candidate. A CT spine was performed to rule out
a paraspinal abscess in the setting of back pain. The patient
could not undergo an MRI because of a temporary pacemaker that
was placed.
The patient was followed clinically by observing his fever
curves, blood cultures, and PR interval. He was transferred to
floor on the evening of [**2188-9-18**] and remained afebrile. An ID
consult was placed to help guide antibiotic therapy as an
outpatient. Ceftriaxone was felt to be the preferred regimen,
however, the patient could not have a PICC line placed because
of the location of his temporary pacemaker lead and his AV
fistula. In concert with ID it was decided to discharge the
patient on vancomycin and gentamycin to be received with
hemodialysis. He received these medications after dialysis on
the day of discharge. Vancomycin and gentamicin will be
continued for at least 6 weeks and will follow-up with ID as an
outpatient.
Given the possibility of complete heart block, an external
pacemaker was placed. He will follow-up with EP as an outpt.
# ESRD on HD: The patient did not receive scheduled dialysis on
arrival as there was not pressing indication for dialysis, and
renal reevaluated the pt the morning following admission. The
patient lytes were monitored closely and he was continued on
nephrocaps, phoslo, cinacalcet, and [**Date Range **]. He was
eventually placed on his regular dialysis schedule of Tuesday,
Thursday, Saturday and received dialysis on the morning of
discharge.
# Oral thrush: Remained stable and was given nystatin swish and
swallow.
# HIV. The patient's most recent CD4 count was 14 from [**Month (only) 205**]: The
pt was not on HAART do to intolerance to treatment. The patient
was continued on dapsone and bactrim. Per ID, he was discharged
on bactrim ss after hemodialysis and dapsone was stopped.
# Hyponatremia: The patient presented with a serum sodium of
131. This was suspected to be hypovolemic hyponatremia and it
improved after IV fluids. The patient was not hyponatremic at
baseline but had hyponatremia during past admissions. Upon
transfer from the ICU the pt's hyponatremia had normalized.
# Anemia: On admission the patient's hematocrit was 28. His
baseline Hct is 29-34. This was most likely due to ESRD and he
receives Epo with dialysis. His hct remained between 27 and 31
during this admission
# Thrombocytopenia: Platelet count 107 on admission and up to
177 on discharge. His platelet count was likely low in the
setting of an acute infection.
# Elevated Troponin: The patient had elevated troponin without
any evidence of ischemia, most likely related to chronic kidney
disease.
# Asthma: Stable. The patient received albuterol prn
# Elevated INR: It is unclear if this is nutritional or related
to a coagulopathy. His INR remained at his baseline.
# Hypertension: Of note, the patient has had problems with
hypertension in the past but his nephrologist reports that his
BP has been increasingly easy to control of late. His
metoprolol was stopped due to hypotension and did not need to be
[**Month (only) **].
# Elevated Alk Phos: Chronic. Most likely from bone as bone alk
phos was elevated when checked in past. Nephrologist planning on
bone scan.
# HCV/HBV: LFTs remained at baseline.
# Chronic pain and h/o opioid dependance: Methadone 40mg tid
was continued per outpatient regimen.
Medications on Admission:
Metoprolol 25mg [**Hospital1 **]
ASA 81mg daily
Nephrocaps PO daily
Oxycodone 5mg for breakthrough pain
Bactrim DS one tablet Q Wed
Cinacalcet 60mg daily
Methadone 40mg TID
[**Hospital1 7222**] 800mg TID
Phoslo 667mg TID
Albuterol inh Q6H prn
Dapsone 100mg daily
Zofran 4mg PO Q6H prn
Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
5. Gentamicin Sulfate (PF) 60 mg/6 mL Solution Sig: One (1)
Intravenous QHD.
6. Vancomycin 500 mg Recon Soln Sig: per HD protocol Recon Soln
Intravenous HD PROTOCOL (HD Protochol).
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
8. Erythromycin 5 mg/g Ointment Sig: One (1) application
Ophthalmic QID (4 times a day) for 7 days.
Disp:*1 tube* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
10. Bactrim 80-400 mg Tablet Sig: One (1) Tablet PO after
hemodialysis.
Disp:*12 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
Mitral valve endocarditis, Strep viridans
Secondary:
HIV/AIDS
Chronic Hepatitis C
HBV+ but HBc equivocal [**10/2186**]
ESRD [**1-19**] HIV Nephropathy on HD
CHF (EF 40-50%)
Chronic low back pain
Discharge Condition:
Afebrile, satting well on room air.
Discharge Instructions:
You were admitted with fevers and low blood presure. This was
due to an infection of your heart valve. For this, we have
started antibiotics that you will get at hemodialysis for at
least 6 weeks.
There have been changes to your home medication regimen. You
should take all your medications as prescribed below. Please
keep all of your follow-up appointments.
Please call your doctor or return to the hospital if you
experience fevers, chest pain, shortness of breath or any other
concerning symptoms.
Followup Instructions:
Please call [**Telephone/Fax (1) 4255**] to make a follow-up appointment with
your primary care doctor/infectious disease doctor within the
next 2 weeks.
Please call [**Telephone/Fax (1) 5518**] to make a follow-up appointment with
Dr. [**First Name (STitle) 28239**] [**Name (STitle) 13177**] in electrophyisiology regarding your
pacemaker in 1 month.
Please call [**Telephone/Fax (1) 60**] to make a follow-up appointment with
your nephrologist, Dr. [**Last Name (STitle) 4883**].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] AV CARE AV CARE [**Location (un) **]
Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2188-10-13**] 9:00
|
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"424.0",
"038.0",
"304.01",
"285.21",
"305.1",
"042",
"338.29",
"588.81",
"996.71",
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"421.0",
"585.6",
"401.9",
"276.1",
"995.92",
"373.00",
"428.23",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"37.78",
"96.6",
"88.72",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14307, 14364
|
7642, 12985
|
293, 333
|
14613, 14651
|
3387, 3387
|
15204, 15853
|
2606, 2695
|
13321, 14284
|
14385, 14592
|
13011, 13298
|
14675, 15181
|
4608, 7619
|
2710, 3368
|
229, 255
|
361, 1860
|
3403, 4592
|
1882, 2429
|
2445, 2574
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,943
| 138,180
|
33248
|
Discharge summary
|
report
|
Admission Date: [**2172-1-10**] Discharge Date: [**2172-1-20**]
Date of Birth: [**2110-8-11**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Tracheomalacia
Major Surgical or Invasive Procedure:
s/p Y tracheal stent placement
History of Present Illness:
The patient is a 61 yo transfer from St.vincents for
tracheomalacia and bronchomalacia, now s/p IP stenting. The
patient originally presented to an OSH on [**2171-12-19**] for shortness
of breath. He was diagnosed with a CHF exacerbation/new a fib.
During the OSH course, he was found unresposive with a decreased
O2 saturation (unknown exact measurement). He was intubated at
that time. The patient failed extubation and was re-intubated,
bronchoscoped and found to have tracheomalacia. He was most
recently re-intubated on [**2172-1-6**]. Blood and sputum cultures
were growing MRSA; vancomycin was started on [**2172-1-2**]. A TTE/TEE
were negative for vegetations. Of note, while at the OSH he did
have an episode of coffee ground emesis for which an EGD was
performed and showed erosion in the antrum, duodenum and
stomach. From a cardiovascular standpoint, the patient was felt
to be in CHF and had new onset a fib. He was aggressively
diuresed. He was initally started on a cardizem drip for rate
control and was transitioned to PO cardizem with HR's in the
50's-60's. Finally, he was treated with prednisone and
nebulizers for COPD exacerbation.
.
He was transferred to [**Hospital1 18**] on [**2172-1-10**] for IP evaluation. A
bronchoscopy was performed on [**2172-1-11**] which showed significant
tracheobronchial malacia involving the distal trachea, right and
left main stem bronchus. It was decided that he needed a Y stent
to facilitate extubation. He went to the OR on [**2172-1-13**] and had
the Y stent placed. Sputum cultures from [**2172-1-11**] grew sparse
staph aureus and rare gram negative rods.
Past Medical History:
Obesity
DM type II
COPD
CAD
HTN
Hyperlipidemia
Degenerative joint disease
Chronic LE edema
Social History:
Single; h/o 1ppd x >45yrs; No known ETOH or drug use
Family History:
unknown
Physical Exam:
Physical Exam:
Vitals - BP 133/75, HR 91, RR 16, O2 100%
Vent - AC 450x14, PEEP 10, FIO2 100%
General - obese male, intubated and sedated
HEENT - PERRL
Neck - obsese, unable to appreciate JVP given size of neck
CV - RRR
Lungs - diffuse rhonci
Abdomen - obese, non-tender, non-distended
Ext - 1+ pitting edema bilaterally
Pertinent Results:
Imaging:
[**2171-12-23**] OSH ECHO - LV normal, EF 50-55%, RV normal, RV systolic
function normal, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, borderline RA enlargement,
MV normal, TV normal, RV systolic pressure 40-50mmHg, trace
aortic regurg, tracepulm regurg, no pericardial effusion.
[**2172-1-11**] CXR - Likely mild-to-moderate fluid overload and
retrocardiac air space opacity, atelectasis versus developing
pneumonia. Abnormal course of right subclavian central venous
catheter as described. PA and lateral films could further
assess. Repositioning may be necessary.
[**2172-1-12**] CXR - Indwelling devices are unchanged in position.
Appearance of the chest is without change from a recent study
except for slight improved aeration in left retrocardiac region.
Within the imaged portion of the upper abdomen, a 1-cm diameter
radiopaque density is identified overlying the region of the
stomach. Although potentially due to a structure external to the
patient, a small aspirated tooth or other foreign body should
also be considered. Attention to this area on repeat radiograph
following removal of external objects would be helpful in this
regard if warranted clinically
.
Micro:
[**2172-1-11**] Blood - pending
[**2172-1-11**] Sputum - 2+ GPC, 2+ GNR; culture growing spare staph
aureus and rare GNR
Brief Hospital Course:
Patient is a 61-year-old gentleman with obesity, DM, CAD,
Hyperlipidemia who was transferred from an OSH because of
difficulty weaning from ventilator support after developing MRSA
pneumonia. Patient was found to have tracheobroncheomalacia,
ultimately requiring tracheostomy. The following issues were
addressed:
.
# TRACHEOBRONCHOMALACIA/RESPIRATORY FAILURE - Patient was
intubated on 3 occasions at OSH; most recently re-intubated on
[**2172-1-6**]. A bronchoscopy revealed tracheobronchomalacia and he
had a Y stent placed in the OR on [**2172-1-13**]. The Y stent did not
adequately address his tracheobroncomalacia; he had increased
secretions and dropped his lung daily so the Y stent was
removed. He subsequently received a tracheostomy tube on
[**2172-1-17**]. Plan is for patient to be slowly weaned off ventilator
support. Patient is also receiving active diuresis with Lasix.
Please continue to assess his volume status and continue
diuresis until patient is euvolemic and diuresis is tolerated.
# GNR PNEUMONIA - Mr. [**Known lastname 77222**] sputum grew citrobacter and
acinetobacter. He was started on a 7-day course of Meropenem, to
be completed on [**2172-1-24**]. Patient responded well to this
antibiotic therapy.
.
# VAP MRSA PNEUMONIA - has been on vancomycin for MRSA PNA since
[**2172-1-2**] (started at OSH) due to fever and secretions. The
patient completed a 14 day course of vancomycin on [**2172-1-16**].
.
# HEPARIN-INDUCED THROMBOCYTOPENIA: The patient's platelets
dropped early in his admission and he was found to be HIT +. He
was started on an argatroban drip, and oral Warfarin was started
on [**2172-1-19**], to which he will be transitioned. Patient is to
continue Argatroban until he is therapeutic on Coumadin (INR
[**3-2**]) for 48 hours. Please note that Argatroban falsely elevates
INR. When his INR on Argatroban is between [**5-3**], Argatroban
should be held for 4 hours and an INR should be checked; this
INR should be between 2 and 3 for 48 hours before Argatroban can
be discontinued. PATIENT IS TO AVOID ALL HEPARIN PRODUCTS. He
will need to be anticoagulated with Coumadin for 6 months.
PLEASE AVOID ALL HEPARIN PRODUCTS. He will need to be
anticoagulated [**Last Name (un) **] Coumadin for a total of 6 months.
.
# ATRIAL FIBRILLATION - currently rate controlled on metoprolol
25 TID. Please titrate as needed. Also receiving Warfarin as
per above.
.
# HYPERLIPIDEMIA - continue statin
.
# AGITATION - The patient has required intermittent haldol and
ativan for agitiation and pulling at lines while inpatient.
.
# DM - Patient was maintained on insulin sliding scale
.
# NUTRITION: PEG tube was placed and patient was started on tube
feeds for nutrition.
.
# PICC - Patient had PICC placed in R arm on [**2172-1-20**] for
antibiotics and Argatroban. Please do NOT USE HEPARIN for
flushes. PICC should be discontinued once antibiotics regimen
and Argatroban regimen is complete.
Medications on Admission:
Medications on Admission to OSH:
Actoplus 15/500 daily
Actoplus 15/850 [**Hospital1 **]
K lor 10 daily
Lipitor 20mg daily
Glipizide 10mg daily
Verapamil 80mg TID
Lasix 40mg daily
Tramadol 50mg QID
.
Medications on Admission to [**Hospital1 18**]:
Lasix 40mg IV q12 hrs
Prevacid
KCL 40mEq daily
Cardizem 60mg q8hrs
Combivent 6 puffs q4hrs
Heparin SQ
Zocor 40mg daily
Vancomycin 900mg IV q12hrs
Prednisone 30mg PO daily
Insulin
Ativan PRN
Dilaudid PRN
Nystatin PRN
Dulcolax PRN
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours) as needed for shortness
of breath or wheezing.
5. Insulin Regular Human 100 unit/mL Solution Sig: 1-20 units
Injection ASDIR (AS DIRECTED): as directed by the sliding scale.
6. Argatroban 100 mg/mL Solution Sig: 1-100 units Intravenous
INFUSION (continuous infusion): per scale (titrate to PTT).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
10. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg)
Intravenous Q6H (every 6 hours) for 3 days: last day [**2172-1-24**].
11. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
TID (3 times a day).
12. Haloperidol Lactate 5 mg/mL Solution Sig: Five (5) mg
Injection [**Hospital1 **] (2 times a day) as needed for agitation.
13. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Tracheobronchomalacia
GNR PNA
MRSA PNA
A Fib
Discharge Condition:
Stable, on minimal vent settings
Discharge Instructions:
You were admitted to the hospital because you had a prolonged
intubation after a servere PNA. You developed a condition
termed tracheobronchomalacia which makes breathing difficult.
We were unable to get you off of the ventilator and you needed a
tracheostomy to help you breath. We are sending you to rehab to
help wean you off of the machine. Hopefully, at some point in
the future the tracheostomy can be removed.
You also had 2 seperate pneumonias. One is still being treated.
You need to complete a 7 day course of Meropenom (an
antibiotic). The last day will be [**2172-1-24**].
You completed a 14 day course of vancomycin for a MRSA pneumonia
on [**2172-1-16**].
you also developed a condition called HIT. With this condition
we need to thin your blood to prevent blood clots. You were
started on argatroban, which is a blood thinner and you are
being transitioned to coumadin. Your first dose of coumadin was
on [**2172-1-19**].
Note to rehab: Argatroban falsely elevates INR so at rehab, when
his INR is between [**5-3**], his argatroban should be held for 4
hours and an INR should then be checked. His goal INR is [**3-2**].
He should be therapeutic on coumadin for 2 days prior to
discontining the argatroban. Please avoid all heparin products.
He will need to be anticoagulated for 6 months.
Followup Instructions:
- Please follow up with your PCP after discharge from rehab.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"491.21",
"V09.0",
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"278.00",
"518.81",
"482.83",
"482.41",
"250.00",
"427.31",
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icd9cm
|
[
[
[]
]
] |
[
"43.11",
"96.71",
"96.72",
"33.23",
"96.6",
"96.05",
"31.1",
"38.93",
"96.04"
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icd9pcs
|
[
[
[]
]
] |
8752, 8831
|
3898, 6834
|
289, 321
|
8920, 8955
|
2536, 3875
|
10326, 10502
|
2170, 2179
|
7360, 8729
|
8852, 8899
|
6860, 7337
|
8979, 10303
|
2209, 2517
|
235, 251
|
349, 1970
|
1992, 2084
|
2100, 2154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,029
| 135,161
|
13492
|
Discharge summary
|
report
|
Admission Date: [**2110-5-19**] Discharge Date: [**2110-5-23**]
Date of Birth: [**2066-10-31**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftazidime / Carbamazepine / Cephalosporins /
cefepime
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Seziure, hypotension
Major Surgical or Invasive Procedure:
Central Line placement
History of Present Illness:
This is a 43 year-old female with a past medical history of
[**Doctor Last Name **] encephalitis, epilepsy, right hemiparesis, global
aphasia, tracehal stenosis, tracheobronchomalacia, chronic
tracheostomy, and recent ICU admissions for pneumonia and UTI,
who initially presented from group home to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] earlier
today seizure activity, including eye fluttering and lip
smacking. At [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], she recived ativan, then valium.
She was hypotensive, and had no IV access, thus was transferred
to [**Hospital1 18**] for further management. Baseline BP's 90's based on
prior OMR notes.
.
In the ED, initial vs were: 98.4 74 84/60 20 100% 10L. Patient
was given 2 mg ativan IV, which did break seizure. Groin access
was established in L femoral. Seen by neurology who recommended
checking levels of all anti-epileptics. Labs notable for pyuria
and hematuria so received meropenem *1 for presumed urosepsis.
Her BP's dipped into the mid 80's and then improved to 90's with
2L fluid hydration before dropping again and being started on
norepinephrine. She is on her third liter of NS at arrival to
the ED. She has had no signs of hypoperfusion and no
tachycardia. Urine output has been good and lactate was normal.
She has been hypothermic, however, to 96 by rectal temp. Of
note, she has a history of hypothermia, particularly when
infected. On transfer, temp 96.8 69 91/43 100% on 50%
humidified trach mask. Just before pt was to be sent she became
bradycardic and was found to be actively seizing (increased
tongue protrusion, eye deviation to the left). She was given 2
mg ativan. Neuro recommended giving 300 mg IV phenytoin for load
and then restart her home dose anti-epileptics.
Past Medical History:
1. [**Doctor Last Name **] encephalitis
2. Epilepsy
3. Partial left hemispherectomy at age 19 complicated by right
hemiparesis and partial aphasia
4. Mental retardation
5. Left thoracolumbar scoliosis
6. Vagal nerve stimulator implanted [**12-7**], needs battery change
7. h/o Aspiration pneumonias, now on scopolamine patch
8. S/p PEG placement using T tube
9. S/p tracheostomy
10. MRSA line infection in the past
11. Hx multiple UTIs, Urosepsis (enterococcus, other)
12. Difficult venous access requiring femoral sticks
13. Constipation
14. Mood disorder, on SSRI; also Zyprexa
- dense global aphasia w/ right hemiparesis
- right spastic hemiplegia
- tracheal stenosis and tracheobroncomalacia (trach dependent)
- recent h/o Pseudomonas aspiration PNA requiring
hospitalization
- major depression
Social History:
No history of tobacco, alcohol, illicit drug use. Lives in a
group home.
Family History:
No family history of seizures or [**Doctor Last Name **].
Physical Exam:
On admission:
Vitals: T: 34.5 via rectal probe BP: 122/88 P: 52 R: 18 O2: 100%
General: Sedated, withdraws to deep sternal rub, otherwise
unrepsonsive
HEENT: Eyes deviated to left with right eye nystagmus, tongue
protrusion
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally in anterior field, on
trach mask, no wheezes, rales, ronchi
CV: Bradycradic, Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: slightly firm, non-tender, non-distended, hypoactive
bs, no rebound tenderness or guarding, no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
.
[**2110-5-18**] 11:05PM BLOOD WBC-8.3# RBC-3.36* Hgb-10.4* Hct-31.7*
MCV-94 MCH-30.8 MCHC-32.6 RDW-16.4* Plt Ct-169
[**2110-5-18**] 11:05PM BLOOD Neuts-73.7* Lymphs-22.9 Monos-2.0 Eos-1.2
Baso-0.2
[**2110-5-20**] 03:29AM BLOOD PT-15.1* PTT-50.2* INR(PT)-1.3*
[**2110-5-18**] 11:05PM BLOOD Glucose-83 UreaN-20 Creat-0.7 Na-138
K-3.4 Cl-99 HCO3-28 AnGap-14
[**2110-5-18**] 11:05PM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.6 Mg-2.3
[**2110-5-18**] 11:05PM BLOOD Phenyto-13.7
[**2110-5-19**] 01:37AM LACTATE-0.6
DISCHARGE LABS:
[**2110-5-22**] 10:45AM BLOOD WBC-2.6* RBC-3.07* Hgb-9.6* Hct-30.1*
MCV-98 MCH-31.4 MCHC-32.1 RDW-16.7* Plt Ct-150
[**2110-5-20**] 09:37AM BLOOD Neuts-47.4* Lymphs-41.7 Monos-5.7
Eos-4.1* Baso-1.0
[**2110-5-22**] 10:45AM BLOOD Plt Ct-150
[**2110-5-22**] 10:45AM BLOOD Glucose-88 UreaN-11 Creat-0.6 Na-144
K-4.0 Cl-112* HCO3-26 AnGap-10
[**2110-5-19**] 04:39AM BLOOD ALT-22 AST-19 LD(LDH)-199 AlkPhos-189*
Amylase-260* TotBili-0.5
[**2110-5-22**] 10:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.9
[**2110-5-21**] 05:08AM BLOOD Phenoba-30.9 Phenyto-15.5
MICRO:
Urine culture [**5-19**]:
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ S
TRIMETHOPRIM/SULFA---- =>16 R
Resp culture [**5-19**]:
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
All blood cultures no growth to date
.
[**2110-5-22**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2110-5-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-5-21**] URINE URINE CULTURE-negative
[**2110-5-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-5-21**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-5-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-5-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-5-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {PSEUDOMONAS AERUGINOSA} INPATIENT
[**2110-5-19**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
INPATIENT
[**2110-5-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2110-5-19**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
.
CXR on admission
PORTABLE AP CHEST RADIOGRAPH: Neurostimulator control device
overlies the left hemithorax obscuring portions of the left
hemithorax. A tracheostomy tube is in standard position.
Bilateral low lung volumes are responsible for crowding of
vessels, but a dense band of right infrahilar atelectasis is
new. There is no appreciable pleural effusion and no
pneumothorax.
Brief Hospital Course:
43 year-old female with a past medical history of complicated
epilepsy, chronic trach, presenting with seziures, urosepsis.
#. Urosepsis: Patient was initially on levophed, which was
weaned off. Blood pressures were fluid responsive afterwards.
Likely source of infection based on urinalysis, on tobramycin
through [**5-28**] for 10 day course for complicated UTI (given
recurrent UTIs in past). Tobra used over meropenem due to risk
of lowering seizure threshold with [**Last Name (un) 2830**].
***ACTION ITEMS***
- Patient will need repeat LFT's and chemistry 10 on [**2110-5-28**]
(these were normal on discharge)
- Complete 10 day course of Tobramycin on [**2110-5-28**]
#. Seziure: Patient has history of epilepsy and [**Doctor Last Name **]
encephalitis. Increased frequency likely triggered in setting
of infect, toxic/metabolic. She is on a four drug antiepilpetic
regimen at baseline, with vagal stimulator. Neuro interrogated
vagal nerve stimulator. Per nurse, seziure activity consists of
right eyelid fluttering, right sided lip quivering. She was
continued on home doses of phenobarb, phenytoin, zonisamide,
keppra with appropriate levels inhouse.
.
#. Leukopenia: Likely side effect of anti-epileptic meds. Going
back in OMR, WBC is usually [**1-10**] when ill. Trending up on d/c.
.
#. Tracheal stenosis, tracheobronchomalacia, s/p trach: Patient
with stable trach settings. No CXR evidence of pneumonia. Had
been treated for MRSA and psuedomonas pneumonia earlier in [**Month (only) 116**].
Cuff replaced several weeks after fell out. She was continued
on duonebs. Pseudomonas in respiratory culture felt to be
colonization given lack of clinical PNA.
.
# HYPOTHERMIA: Per her nurses at the group home, the patient's
temperatures are chronically low, and she becomes more
hypothermic when infected. Infectious workup as above.
.
# EDEMA: Patient has history of lower extremity edema, for which
she takes lasix. Held diuretics in face of hypotension, should
be restarted when SBP>100's
.
# HYPOTHYROIDISM: Continued levothyroxine.
# ANEMIA: Pt is chronically anemic with Hct 27-32. stable.
# DEPRESSION: Pt was continued on her home regimen of olanzipine
and fluoxetine.
# NUTRITION: Pt received home tube feeds. Nutrition was
consulted.
# ACCESS: Tunnelled femoral line placed for IV antibiotics.
Medications on Admission:
1. phenobarbital 30 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. phenobarbital 30 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. levetiracetam 100 mg/mL Solution Sig: Fifteen (15) ml PO BID
(2 times a day).
4. levetiracetam 100 mg/mL Solution Sig: Ten (10) ml PO DAILY
(Daily).
5. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
6. Dilantin Infatabs 50 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO three times a day.
7. fluoxetine 20 mg/5 mL Solution Sig: Five (5) ml PO DAILY
(Daily).
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO HS (at bedtime).
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
15. Miconazole powder 2% PRN
16. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for dry skin.
** Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) HELD in-house for hypotension.
Discharge Medications:
1. phenobarbital 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. phenobarbital 60 mg Tablet Sig: One (1) Tablet PO twice a
day.
3. levetiracetam 100 mg/mL Solution Sig: Fifteen (15) mL PO BID
(2 times a day).
4. levetiracetam 100 mg/mL Solution Sig: Ten (10) mL PO NOON (At
Noon).
5. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO once a
day.
6. phenytoin 50 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables
PO TID (3 times a day).
7. fluoxetine 20 mg/5 mL Solution Sig: Five (5) cc PO DAILY
(Daily).
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every four (4) hours.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
13. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
14. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal DAILY (Daily).
15. senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
16. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
17. Tobramycin 500 mg IV Q24H
Day 1 = [**2110-5-19**]
18. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
19. camphor-menthol Topical
20. Outpatient Lab Work
21. Outpatient Lab Work
Please obtain chemistry 10 and LFT's on [**2110-5-28**]. PCP will follow
up.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]Hospice
Discharge Diagnosis:
PRIMARY DIAGNOSES
Urinary Tract Infection
Autonomic instability
Seizures
SECONDARY DIAGNOSES
[**Doctor Last Name **] encephalitis
Epilepsy
Mental retardation
Left thoracolumbar scoliosis
h/o Aspiration pneumonias, now on scopolamine patch
S/p PEG placement using T tube
S/p tracheostomy
Mood disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for seizures and low blood pressure.
Your blood pressure was normalized and your anti-seizure
medications were optimized. You were also started on an
antibiotic for a urinary tract infection.
.
While you were here we made the following changes to your
medications:
We STARTED you on scopolamine
We STARTED you on Tobramycin through [**5-28**]
STOP your lasix until systolic blood pressures >100
.
You should take your other medications as directed.
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2110-8-4**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 1217**], MD [**Telephone/Fax (1) 2928**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"E947.8",
"296.90",
"244.9",
"458.9",
"276.52",
"519.19",
"V44.0",
"780.65",
"V49.86",
"599.0",
"296.20",
"319",
"041.4",
"348.89",
"345.81",
"782.3",
"342.11",
"041.7",
"323.81",
"788.5",
"285.9",
"288.50",
"342.81",
"E849.8",
"784.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
12654, 12708
|
7210, 9544
|
353, 377
|
13054, 13054
|
3886, 3886
|
13745, 14044
|
3146, 3205
|
10967, 12631
|
12729, 13033
|
9570, 10944
|
13232, 13722
|
4428, 7187
|
3220, 3220
|
292, 315
|
405, 2216
|
3902, 4411
|
3234, 3867
|
13069, 13208
|
2238, 3039
|
3055, 3130
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,412
| 113,409
|
10341+56135
|
Discharge summary
|
report+addendum
|
Admission Date: [**2115-10-22**] Discharge Date: [**2115-10-24**]
Date of Birth: [**2055-5-29**] Sex: F
Service:
CHIEF COMPLAINT: Malaise, nausea and vomiting.
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 34331**] is a 60-year-old
woman with a prior medical history of end stage renal disease
secondary to polycystic kidney disease on hemodialysis with
multiple graft clot and revisions secondary to non compliance
with Coumadin, also with hypertension and chronic obstructive
pulmonary disease, discharged from vascular surgery service
yesterday after having been unable to underlie hemodialysis
secondary to a thrombosed graft. The patient missed several
Coumadin doses prior to the graft thrombosing. Subsequently
she missed hemodialysis. On [**7-8**] she had a thrombectomy and
she was discharged. She went to have hemodialysis on [**7-10**]
but was unable to dialyze again as access was not obtained.
She was readmitted to [**Hospital1 69**]
for thrombectomy which was performed on [**2115-7-10**] and is now
being transferred to medicine for complaint of malaise,
nausea, vomiting, diarrhea. The patient is a poor historian
but he reports 2-3 weeks of intermittent vomiting and nausea
with subsequent decreased po intake, including her
medications. She denies any abdominal pain, fever, chills,
hematemesis, coffee ground or change in symptoms with food.
She complains of diarrhea of loose brown stool, no melena, no
blood or mucus. Stools are not clearly related to eating and
she can have [**5-31**] bowel movements per day which vary in size.
No recent history of travel, no sick contacts at home, no
weight loss. The patient also complains of chronic cough
which has been increased recently. She denies any shortness
of breath, chest pain, changes in sputum color or hemoptysis.
She uses inhalers more than usual but denies any wheezes or
other upper respiratory infection symptoms.
PAST MEDICAL HISTORY: Significant for end stage renal
disease on hemodialysis secondary to polycystic kidney
disease with multiple clotted graft followed by revision.
Hypertension, depression, chronic obstructive pulmonary
disease.
ALLERGIES: Penicillin per patient report.
MEDICATIONS: RenaGel 800 mg tid, Nephrocaps one q d,
Albuterol as needed, Atrovent as needed, Coumadin.
SOCIAL HISTORY: Lives with her husband and daughter. She
has a positive tobacco history which consisted of two packs
per day for 30 years. She quit one year ago, denies any
alcohol use and reports that her family helps her with her
medications.
PHYSICAL EXAMINATION: Temperature 96.4, heart rate 92, blood
pressure 115/50, respiratory rate 16 with an oxygen
saturation of 98% on room air. General appearance, sleeping
but arousable, in no acute distress with occasional
congestive cough. HEENT: Anicteric, pupils are equal,
round, and reactive to light, oropharynx clear. Neck supple
without JVD. Chest, positive mild inspiratory plus
expiratory wheezes with decreased air movement throughout, no
rales. Heart, regular rate and rhythm, no murmurs, rubs or
gallops. Abdomen soft, nontender, nondistended with positive
bowel sounds, no right upper quadrant tenderness to
palpation, no mass. Extremities, no clubbing, cyanosis or
edema, Pneumo boots on. Neuro, alert and oriented times
three, cranial nerves II through XII intact. Strength
extremities not tested secondary to surgery today [**4-26**], left
upper extremity and bilateral lower extremities. Babinski
downgoing.
LABORATORY DATA: WBC 8.8, hematocrit 34.4, platelet count
184,000, PT 13, PTT 27, INR 1.2, sodium 136, potassium 5.2,
chloride 95, CO2 24, BUN 58, creatinine 9.2, glucose 82.
Albumin 3.7, ALT 11, AST 15, alkaline phosphatase 117, total
bilirubin 0.5, amylase 61, lipase 47. EKG on [**7-10**], sinus
tachycardia at 105, no acute ST or T wave changes. C. diff
negative. Radiology data: KUB, nonspecific bowel gas
pattern, no dilated loops. Chest x-ray, hyperinflated lungs,
no evidence of pneumonia or congestive heart failure.
Urinalysis on [**10-6**] cloudy, large blood, positive nitrites and
leukoesterase, 100 protein, PH 9.0, more than 50 RBC and WBC
and many bacteria.
HOSPITAL COURSE: Mrs. [**Known lastname 34331**] is a 60-year-old woman with end
stage renal disease secondary to polycystic kidney disease on
hemodialysis and also with chronic obstructive pulmonary
disease, presenting with a few weeks of intermittent nausea
and vomiting, diarrhea and decreased po intake.
GI: Etiology of nausea and vomiting and diarrhea is unclear;
could be related to renal function as the patient has missed
dialysis sessions during the past weeks and her BUN and
creatinine have been elevated. During her hospital course
she also related that the nausea, vomiting and diarrhea had
been occurring the past when she missed hemodialysis or her
BUN and creatinine were particularly elevated. The nausea
and vomiting resolved throughout her hospital stay right
after she underwent dialysis but continued to appear in a
milder form in between dialysis sessions.
Renal failure: The patient requires hemodialysis. The
patient presented to medicine status post AV graft
thrombectomy with primary graft repair. Not withstanding the
thrombectomy and despite the heparin drip, the graft remained
non palpable but positive to Doppler. Heparin was increased
to achieve a PTT between 60 and 90 and Coumadin was started.
A Perma-cath was placed on [**2115-7-11**] to be used for dialysis
until the graft would be cleared by vascular surgery. The
patient received dialysis through the Perma-cath on [**2115-7-12**].
Meanwhile, the rate of the heparin drip had to be increased
as the patient had difficulty in achieving PTT therapeutic
range of 60-90. An arteriographic exploration of the graft
was planned while the patient remained on heparin and
Coumadin was titrated to achieve the therapeutic INR between
2.5 and 3.5. As arteriography could not be easily scheduled
during the [**Hospital 228**] hospital stay, the procedure was
scheduled as an outpatient for one week later. The patient
continued to remain in hospital until [**2115-7-17**] in the attempt
to achieve a therapeutic INR so that she could be discharged
on Coumadin only. However, as this did not happen by [**7-17**]
and the patient was eager to go home, she was discharged on
Lovenox. Teaching was performed by a teaching nurse and her
daughter appeared to be able to inject the patient with
Lovenox. She was instructed to have her daughter inject her
with Lovenox and have her INR checked at the local clinic
where she had been going before. She would be returning to
the hospital for an outpatient revision of the graft.
[**Doctor First Name 4623**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4624**], MD [**MD Number(2) 4625**]
Dictated By:[**Last Name (NamePattern1) 6831**]
MEDQUIST36
D: [**2115-10-30**] 18:53
T: [**2115-11-4**] 19:30
JOB#: [**Job Number **]
Name: [**Known lastname 6044**], [**Known firstname **] Unit No: [**Numeric Identifier 6045**]
Admission Date: [**2115-7-10**] Discharge Date: [**2115-7-17**]
Date of Birth: [**2055-5-29**] Sex: F
Service:
ADDENDUM:
This is an addendum to previous dictation.
CONDITION ON DISCHARGE: The patient's condition at discharge
was fair.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Nausea and vomiting.
2. Uremia and elevated creatinine secondary to having missed
dialysis.
DISCHARGE MEDICATIONS:
1. Lovenox.
2. Renagel.
3. Nephrocaps.
4. Albuterol.
5. Atrovent.
6. Coumadin.
FOLLOW UP PLAN: Patient is instructed to call the surgeon's
office for further instructions of procedure on Friday.
DR. [**Name (NI) 6046**] [**Last Name (NamePattern1) 6047**]
Dictated By:[**Last Name (NamePattern1) 6048**]
MEDQUIST36
D: [**2115-10-30**] 18:57
T: [**2115-10-31**] 10:48
JOB#: [**Job Number 6049**]
|
[
"585",
"996.73",
"401.9",
"753.12",
"492.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95",
"39.49"
] |
icd9pcs
|
[
[
[]
]
] |
7537, 7978
|
7416, 7514
|
4200, 7293
|
2584, 4182
|
147, 178
|
207, 1928
|
1951, 2312
|
2329, 2561
|
7318, 7395
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,345
| 128,084
|
35228+57986
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-10-23**] Discharge Date: [**2145-11-1**]
Date of Birth: [**2071-10-23**] Sex: M
Service: UROLOGY
Allergies:
Niacin / Tricor / Allopurinol
Attending:[**First Name3 (LF) 6440**]
Chief Complaint:
s/p bladder cystectomy w/ileal conduits for bladder cancer
Major Surgical or Invasive Procedure:
s/p bladder cystectomy w/ileal conduits for bladder cancer
History of Present Illness:
This is a 73-year-old Portuguese speaking male w/h/o CAD, COPD,
PVDz s/p ileal stent w/recent dx of transitional cell carcinoma
who is admitted to [**Hospital Unit Name 153**] after scheduled bladder cystectomy
w/ileal conduits. Per report, pt had sx of dysuria at home.
.
On [**2145-10-24**], pt was transfused 2 units packed red blood cells for
HCT 26.1.
.
During the procedure, he had ~700cc EBL, received 3L
crystalloids. He received 1 unit of PRBCs. He received
fentanyl/sufentanyl/vecuronium for GETA. The procedure was
without complications. He was on neosynephrine only very briefly
intraoperatively.
He was transferred to the ICU intubated, still sedated,
hemodynamically stable off of pressors.
.
Unable to complete ROS at this time due to pt sedated/intubated.
.
Past Medical History:
transitional cell carcinoma - Pathology is pending from right
distal ureter
Hypertension
post polio syndrome
hyperlipidemia
DM2
monoclonal gammopathy
peripheral vascular disease s/p left common iliac arterial
stent, right common femoral arterial stent
synovial osteochondromatosis of the left hip
COPD, tobacco abuse
aortic stenosis aortic valve area 0.6cm2
history of urinary tract infection with pseudomonas
Social History:
Smoking one pack a day for 50 years, no current
alcohol abuse. No illicit drug use.
Family History:
nc
Physical Exam:
on Presentation to ICU:
Vitals: T: 98.1 BP: 113/58 HR: 71 RR: 11 O2Sat: 100% AC FiO2 50%
TV 650cc RR 10 PEEP 5
GEN: intubated, sedated, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD appreciated, but right IJ in place, carotid pulses
brisk, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: ostomy site note draining serosanguinous fluid, JP drain in
place, wound coverings clean, Soft w/o apparent tenderness,
hypoactive BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: intubated, sedated, opens eyes to verbal stimuli.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2145-10-23**] 09:00PM WBC-3.7* RBC-2.60* HGB-8.3* HCT-26.1*
MCV-101* MCH-32.1* MCHC-31.9 RDW-17.5*
[**2145-10-23**] 09:00PM NEUTS-63.4 LYMPHS-28.0 MONOS-5.1 EOS-3.3
BASOS-0.1
[**2145-10-23**] 09:00PM PLT COUNT-281
.
[**2145-10-23**] 09:00PM PT-13.7* PTT-27.6 INR(PT)-1.2*
.
[**2145-10-23**] 09:00PM GLUCOSE-123* UREA N-43* CREAT-1.3* SODIUM-144
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-27 ANION GAP-14
[**2145-10-23**] 09:00PM ALT(SGPT)-21 AST(SGOT)-20 ALK PHOS-86 TOT
BILI-0.2
[**2145-10-23**] 09:00PM ALBUMIN-4.4 CALCIUM-9.6 PHOSPHATE-4.2
MAGNESIUM-2.5
.
[**2145-10-23**] 09:15PM URINE RBC-21* WBC-668* BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2145-10-23**] 09:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
.
[**2145-10-23**] Pre-op CXR: IMPRESSION:
1. Probable mild volume overload.
2. Trace right pleural effusion.
3. Underlying COPD.
Brief Hospital Course:
Patient was admitted to the Urology service after undergoing
radical cystectomy and ileal conduct. No concerning
intraoperative events occurred; please see dictated operative
note for details. Patient received perioperative antibiotic
prophylaxis and deep vein thrombosis prophylaxis with
subcutaneous heparin. With the passage of flatus, patient's diet
was advanced. The patient was ambulating with assistance from
physical therapy and pain was controlled on oral medications by
this time. The ostomy nurse saw the patient for ostomy teaching.
He was seen by rheumatology for his gout and recommendations
were followed. At the time of discharge the wound was healing
well with no evidence of erythema, swelling, or purulent
drainage. The ostomy was perfused and patent. Patient is
scheduled to follow up in one weeks time with in clinic for
wound check. He was discharged to a rehab facility for physical
therapy.
Medications on Admission:
Albuterol neb 4 times daily
Uriced 1 tablet 4 times daily
Metamucil 1 packet daily
Colace 200mg twice daily
Finasteride 5mg daily
Fndapamide 2.5 mg daily
Glipizide 10mg at breakfast, 5 mg at lunch, 5mg w/dinner
Lipitor 40mg daily
Ambien 5mg daily
Advair 250/50 mcg 1 puff twice daily
Metoprolol succinate 50mg daily
Lopid 600mg daily
Actos 45mg daily
Potassium chloride 20mEq daily
Indocin 50mg daily prn pain
ibuprofen 600mg q6 hours
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-16**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-16**] Inhalation Q6H (every 6 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
bladder cancer
Discharge Condition:
stable
Discharge Instructions:
-Please resume all home meds
-Do not drive while taking oxycodone. Please take Tylenol in
addition to oxycodone, and transition to Tylenol as pain
improves.
-You may shower, but do not immerse incision, no tub
baths/swimming.
-Small white steri-strips bandages will fall off in [**4-21**] days,
you may remove at that time if irritating.
-Call if incision becomes markedly more red, swollen, or begins
to drain purulent fluid, or for fever more than 101.5.
-Please refer to visiting nurses (VNA) for management of the
ileal conduct.
Followup Instructions:
1-2 weeks
Completed by:[**2145-11-1**] Name: [**Known lastname 12913**],[**Known firstname 12914**] R. Unit No: [**Numeric Identifier 12915**]
Admission Date: [**2145-10-23**] Discharge Date: [**2145-11-1**]
Date of Birth: [**2071-10-23**] Sex: M
Service: UROLOGY
Allergies:
Niacin / Tricor / Allopurinol
Attending:[**First Name3 (LF) 11353**]
Addendum:
Rheumatology in 4 weeks- call [**Telephone/Fax (1) 4874**] to schedule
appointment
Major Surgical or Invasive Procedure:
cystectomy with ileal loop
History of Present Illness:
Radical Cystectomy and IC/BPLND
IVF: 3.0L EBL:700
Plan:
To [**Hospital Unit Name 12916**] PCA; if poor pain control, good [**Name6 (MD) 12917**] and Crt, may give
Toradol
EKG; lop 5q4
CXR for IJ, IS x 10
NPO/NGT/Pepcid; Reglan RTC; KUB for stent placement
D5LR @ 150
RISS vs Insulin gtt
SCH2
Ancef/Gent/Flagyl x 48hours
NGT, stoma with stents (left at oblique), JP
R IJ, R aline, PIV x 2
PACU labs, am labs
Past Medical History:
transitional cell carcinoma - Pathology is pending from right
distal ureter
Hypertension
post polio syndrome
hyperlipidemia
DM2
monoclonal gammopathy
peripheral vascular disease s/p left common iliac arterial
stent, right common femoral arterial stent
synovial osteochondromatosis of the left hip
COPD, tobacco abuse
aortic stenosis aortic valve area 0.6cm2
history of urinary tract infection with pseudomonas
Social History:
Smoking one pack a day for 50 years, no current
alcohol abuse. No illicit drug use.
Family History:
nc
Brief Hospital Course:
Brief Hospital Course:
Patient was admitted to the Urology service after undergoing
radical cystectomy and ileal conduct. No concerning
intraoperative events occurred; please see dictated operative
note for details. Patient received perioperative antibiotic
prophylaxis and deep vein thrombosis prophylaxis with
subcutaneous heparin. With the passage of flatus, patient's diet
was advanced. The patient was ambulating with assistance from
physical therapy and pain was controlled on oral medications by
this time. The ostomy nurse saw the patient for ostomy teaching.
He was seen by rheumatology for his gout and recommendations
were followed. At the time of discharge the wound was healing
well with no evidence of erythema, swelling, or purulent
drainage. The ostomy was perfused and patent. Patient is
scheduled to follow up in one weeks time with in clinic for
wound check. He was discharged to a rehab facility for physical
therapy.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**12-16**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**12-16**] Inhalation Q6H (every 6 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
Discharge Diagnosis:
bladder cancer
Discharge Condition:
stable
Discharge Instructions:
-Please resume all home meds
-Do not drive while taking oxycodone. Please take Tylenol in
addition to oxycodone, and transition to Tylenol as pain
improves.
-You may shower, but do not immerse incision, no tub
baths/swimming.
-Small white steri-strips bandages will fall off in [**4-21**] days,
you may remove at that time if irritating.
-Call if incision becomes markedly more red, swollen, or begins
to drain purulent fluid, or for fever more than 101.5.
-Please refer to visiting nurses (VNA) for management of the
ileal conduct.
Rheumatology in 4 weeks- call [**Telephone/Fax (1) 4874**] to schedule
appointment
Followup Instructions:
1-2 weeks with Dr. [**Last Name (STitle) 2028**]
Rheumatology in 4 weeks- call [**Telephone/Fax (1) 4874**] to schedule
appointment
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 4982**] MD [**MD Number(1) 4983**]
Completed by:[**2145-11-1**]
|
[
"V13.02",
"518.5",
"424.1",
"414.01",
"496",
"305.1",
"272.4",
"518.89",
"443.9",
"273.1",
"427.31",
"599.0",
"138",
"041.7",
"727.82",
"274.0",
"188.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.04",
"57.71",
"56.51",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
10691, 10761
|
8473, 9393
|
7404, 7433
|
10820, 10829
|
2521, 3448
|
11500, 11793
|
8423, 8427
|
9416, 10668
|
10782, 10799
|
4415, 4852
|
10853, 11477
|
1787, 2502
|
252, 312
|
7461, 7870
|
7892, 8304
|
8320, 8407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,540
| 159,191
|
29973
|
Discharge summary
|
report
|
Admission Date: [**2178-1-21**] Discharge Date: [**2178-1-27**]
Date of Birth: Sex:
Service:
PREOPERATIVE DIAGNOSIS: Bilateral pneumonia.
POSTOPERATIVE DIAGNOSIS: Bilateral pneumonia.
OTHER DIAGNOSES: History of esophageal perforation.
HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old
female who had recently undergone thoracotomy and repair of
an esophageal perforation. The patient had been sent to rehab
but had come back with fevers and shortness of breath. On CT
scan of the chest, it was evident that the patient had
bilateral lower lobe collapse and evidence of bilateral
pneumonia. The patient was begun on antibiotics and had a
bronchoscopy performed on admission.
HOSPITAL COURSE: On the bronchoscopy, there were very
thickened and copious secretions. The patient was brought to
the intensive care unit and monitored. Over the next 3 days,
her white count went down to 12. She had intermittent fever.
Given her overall condition, however, a discussion with the
family was had. After discussion with the family and review
of the patient's condition, it was decided to take the
patient off all mechanical and vasopressor support. The
patient was transferred down to a regular nursing floor. The
patient eventually expired on [**2178-1-27**], after a
hospital stay of 1 week.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(2) 25080**]
Dictated By:[**Name8 (MD) 67551**]
MEDQUIST36
D: [**2178-10-19**] 15:23:04
T: [**2178-10-19**] 22:39:13
Job#: [**Job Number 71557**]
|
[
"294.10",
"995.91",
"428.0",
"V44.4",
"519.19",
"038.9",
"V44.0",
"482.41",
"331.0",
"427.31",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"96.6",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
739, 1560
|
301, 721
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,171
| 126,813
|
29648
|
Discharge summary
|
report
|
Admission Date: [**2151-12-19**] Discharge Date: [**2151-12-24**]
Date of Birth: [**2100-12-19**] Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: This is a 50-year-old male with
unknown past medical history other than bilateral inguinal
hernia repairs that was admitted to the trauma service after
suffering a motor vehicle collision as the driver. The
details of the accident, per report, were that he was
extricated by EMS at the scene and intubated there for airway
protection and question of possible heroin use prior to the
accident with track marks noted over his right arm. His GCS
at the scene was 8. He was also given Narcan at that time
without affect.
The patient - on arrival to the trauma bay - was
hemodynamically stable and 100% on assist control on the
ventilator. His heart rate was in the 70s, and his blood
pressure was 153/73. His primary survey was unremarkable,
including a FAST exam. His initial toxicology screen revealed
positive for benzodiazepines, opiates and cocaine. All of his
imaging at the time of admission; including a trauma series
with chest x-ray and pelvis were unremarkable; along with CAT
scans of the head, neck and torso also revealed no obvious
injuries.
PHYSICAL EXAMINATION ON ADMISSION: The patient arrived with
a temperature of 99.8 degrees Fahrenheit, his heart rate was
74, blood pressure 153/73, respiratory rate of 19 and 100% on
assist control of FIO2 of 99%. His head, ears, eyes, nose,
and throat examination was unremarkable. He was
normocephalic/atraumatic with no hemotympanum. Extraocular
movements were intact throughout. Pupils were equally round
and reactive to light. He revealed an oropharynx that was
clear. His neck was in a hard collar without any obvious
deformity. His trachea was midline. His posterior spine exam
was also unremarkable with no obvious step-offs, deformities
or tenderness. His chest revealed equal breath sounds
bilaterally along with a heart in regular rate and rhythm
with no murmurs, rubs or gallops. His abdomen was
nondistended with normal active bowel sounds. It was
nontender throughout. His extremities revealed no obvious
injury. He was moving all of his extremities at this time and
withdrawing them to pain appropriately. His rectal exam was
guaiac negative with normal tone.
HOSPITAL COURSE: The patient was admitted to the trauma
SICU, having been intubated at the scene; and he was brought
up to there after a brief stent in the emergency room. He was
able to be extubated on hospital day #2 without difficulty;
and he was noted to be ventilating well at this time,
saturating 98% on a 50% face tent. He progressively improved.
However, on the morning of [**12-21**] a code purple was called
in the trauma SICU. He became acutely agitated at that time
and required significant restraining, and doses of Ativan and
Haldol. The psychiatry service arrived and found the man to
be expressing paranoid delusions at this time. They continued
to follow the patient during his stay and contribute
recommendations as needed. By the time of discharge they felt
him safe to be discharged to a sober house, and this was
arranged. The patient was noted to be medically stable at
this time; and had again after multiple surveys not shown any
signs of injury.
DISCHARGE INSTRUCTIONS: The patient will be discharged to a
sober house and to follow up with Dr. [**Last Name (STitle) **] as needed at
([**Telephone/Fax (1) 2537**]. The patient to resume home medications as he
was taking them prior.
[**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2151-12-24**] 16:08:16
T: [**2151-12-24**] 17:12:17
Job#: [**Job Number 71065**]
|
[
"305.60",
"305.40",
"293.0",
"070.32",
"070.54",
"427.89",
"304.01",
"V71.4",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2318, 3274
|
3299, 3821
|
168, 1244
|
1259, 2300
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,332
| 144,224
|
22893+57325
|
Discharge summary
|
report+addendum
|
Unit No: [**Numeric Identifier 59174**]
Admission Date: [**2133-1-13**]
Discharge Date: [**2133-1-30**]
Date of Birth: [**2076-5-26**]
Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
male who presents for evaluation of third nerve palsy. The
patient states that approximately 5-6 weeks ago he developed
an upper respiratory infection, as well as photophobia of the
left eye with double vision, slight drooping of the left
eyelid, and left-sided sharp, shooting headache. The patient
states signs and symptoms have been progressively worsening
over time and now has severe left-sided headache with
photophobia, inability to keep his left eyelid open, nausea
and vomiting. He also complained of right posterior shoulder
numbness that does not radiate anywhere, and denies weakness.
PAST MEDICAL HISTORY: Left cataract surgery in [**2120**].
MEDICATIONS: Ibuprofen.
ALLERGIES: Denies any.
PHYSICAL EXAM: Awake, alert and oriented x 3. Pupils 3-4 mm
on the right, reactive; 5-6 mm on the left and nonreactive.
EOMs full with the exception of the patient's inability to
adduct the left eye, and complete left ptosis of the eyelid,
although patient able to open lid with effort. Remainder of
cranial nerve appeared grossly intact. Full range of motion
and strength of all extremities. Strength was intact
throughout. Sensation intact throughout.
HOSPITAL COURSE: The patient was admitted to the ICU. The
patient was admitted and had a cerebral angio which showed
the presence of a 6 mm multilobulated left PCOM aneurysm,
which exerts mass effect. The patient also had a left MCA
aneurysm, a right ICA bifurcation aneurysm, and a right MCA
aneurysm. Post angio, the patient's vital signs were stable.
He was awake, alert and oriented x 3. No drifts. Smile was
symmetric. He continued to have a left ptosis with left eye,
4-5 mm and nonreactive. Right eye 2 mm and slightly
reactive. Strength was [**4-9**] in all muscle groups.
The patient was preopped and taken to the OR on [**1-15**] for a
left PCOM and MCA aneurysm clipping. The patient tolerated
the procedure well without intraop complication. Postop, he
was monitored in the ICU. His vital signs were stable. His
blood pressure was kept less than
1. He was monitored for alcohol withdrawal for pretty
significant alcohol history. He was on a CIWA scale. He
remained neurologically stable. Visual fields were full.
His EOMs were full. His IPs were full.
Postop, he went for diagnostic angio which showed good
clipping of the aneurysm with no residual. Postop, his vital
signs were stable. He was afebrile. He was intubated,
awake, following commands, off propofol, moving all four
extremities, opened the right eye, but continued to have
persistent left eye ptosis.
On [**1-17**], the patient was awake, alert and oriented x 2,
continued to have the left ptosis with outward deviation,
right pupil was 3.5 mm, the left 4.5. The left continued to
have limited adduction. He had no pronator drift. His
grasps were full. Repetition was intact. His IPs were full.
His naming was intact. His dressing was clean, dry and
intact. He developed hyponatremia with a sodium down to 132.
He was put on a free water restriction and started on salt
tabs 2 gm po tid and had a bolus of Dilantin for a low
Dilantin level. His vital signs remained stable.
The patient was seen by the endocrine service for severe
hyponatremia. The patient was put on a free water
restriction to 1,000 cc/D. Hypertonic saline was
discontinued, and the patient was having his sodium checked
tid.
On [**1-20**], the patient's sodium dropped to 125. The patient
continued on a fluid restriction, and salt tabs were
increased to 3 gm po tid.
On [**1-22**], the patient's sodium level continued to drop.
Renal was consulted. The patient's sodium was down to 119.
His 3 percent saline drip was restarted. The patient had
urine lytes sent and continued on a fluid restriction with 3
gm tid of salt tabs. The patient remained on 3 percent
saline drip for 2-3 days.
On [**1-25**], sodium level was up to 131. The patient's 3
percent saline drip was discontinued. The patient's vital
signs remained stable. Neurologically, he remained awake,
alert and oriented x 3, following commands x 4, with stable
vital signs. The patient's hematocrit dropped to 26.9. He
was transfused with 2 units of packed red blood cells on
[**2133-1-28**]. Repeat crit was 31.5. The patient's vital signs
remained stable. The patient was transferred to the regular
floor on [**2133-1-28**] and remained neurologically stable with
stable vital signs.
He was assessed by physical therapy and occupational therapy
and found to require acute rehab prior to discharge to home.
He will follow-up with Dr. [**Last Name (STitle) 1132**] in 2 weeks. His staples
should be removed on postop day 10.
DISCHARGE MEDICATIONS:
1. Metoprolol 50 mg po bid.
2. Dilantin 200 mg po bid.
3. Famotidine 20 mg po bid.
4. Heparin 5,000 units subcu tid.
5. Nicotine 21 mg topically daily.
6. Oxacillin 2 gm IV q 6 h.
7. Sodium tabs 3 gm po tid.
8. Insulin sliding scale.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: Follow-up with Dr. [**Last Name (STitle) 1132**] in 2 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2133-1-29**] 10:29:53
T: [**2133-1-29**] 10:59:09
Job#: [**Job Number 59175**]
Name: [**Known lastname 10866**],[**Initials (NamePattern4) **] [**Known firstname 651**] Unit No: [**Numeric Identifier 10867**]
Admission Date: [**2133-1-15**] Discharge Date: [**2133-2-10**]
Date of Birth: [**2076-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2339**]
Addendum:
See previous discharge summary for events up to [**2133-1-30**].
After his sodium normalized he was transferred from the ICU to
the neurology floor. During his ICU stay, he spiked to 102.7 on
[**1-23**], and blood cx and urine cx were done. Blood cx returned
[**3-9**] positive for MSSA. UA was positive for enterobacter
pansensitive. The bacteremia was thought to be due to an
arterial line infection, thus the line was pulled and he was
started on vancomycin [**Date range (1) 10868**]. Antibiotics were changed to
oxacillin on [**1-27**] as sensitivities came back sensitive to
oxacillin. Repeat blood cultures were drawn on [**1-29**] and [**5-11**]
grew MSSA, on [**1-30**] one out of two bottles + MSSA, [**2-1**] & [**2-3**] -
NGTD. He was continued on oxacillin per ID recs. In addition,
TTE and TEE were negative for endocarditis. He will continue a
bacteremia workup on the medicine service that includes CT chest
and WBC scan to look for osteomyelitis. He was subsequently
found to have aspiration pneumonia and UTI was treated with
clinda and cipro. f/u Urine cx on [**2-1**] showed no growth. LFTs
should be followed as patient is on oxacillin.
On [**1-30**], he was found to be in rapid afib while getting his TTE.
He was sent back to the floor and cardiology was consulted.
His metoprolol was increased and aspirin was started. TEE
showed EF 50-55%, simple atheromas, + PFO, 1+ MR, 1+ AI.
He is currently being trasferred to the medicine service for
further management of his medical issues.
HOSPITAL COURSE FROM TIME OF TRANSFER TO MEDICINE ON [**2133-2-3**]:
HPI: 56 yo M with remote h/o tob, EtOH, migraines, cataract
surgery, p/w 5-6 weeks of progressive worsening HA, then
developed left eye ptosis, double vision and was admitted on
[**2133-1-14**]. Subsequently found to have multiple (at least
5)aneurysms on MRI now s/p clipping of 2 of those aneurysms, the
Left MCA and Posterior communicating artery. Post op course was
intially complicated by hyponatremia attributed to SIADH, now
resolved, high grade MSSA bacteremia on [**1-23**] ([**3-9**]) secondary to
a line infection (also cultured MSSA) with persistent bactermeia
on [**1-29**]([**5-11**] still positive for MSSA), switched from vancomycin
(started [**2-2**]) to oxacillin on [**1-27**], now s/p negative TEE, chest
CT showing possible septic emboli in addition to possible
aspiration pneumonia, and with new onset afib, now in sinus
rhythm. He is transferred to medicine service from neurosurgery
on [**2-3**].
.
At this time he reports some difficulty with word
finding/cognition that he thinks has improved since surgery. He
denies double vision, light-headedness, dizziness or headache.
Additionally, he complains of cough with mucous production that
he feels has worsened over the past few days. He denies fevers,
chills, night sweats, chest pain or shortness of breath. Denies
hemoptysis. Reports feeling some fatigue from everything he has
been through. Denies abdominal complaints including abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
melena. No fecal incontinence. Denies dysuria, incontinence or
hesitancy or incomplete voiding. He denies other
pains/arthralgias. Says his former picc site is not painful,
does have soreness at current IV site.
HOSPITAL COURSE [**2-3**] on: This is a 56 y/o with h/o smoking,
alcohol abuse, migraines who presented with headaches, CNIII
nerve palsy on [**1-14**] admited to neurosurgery found to have
multiple intracranial aneurysms incl l mca aneurysm with mass
affect, now 2 of which are s/p clipping. Post-op course
complicated by hyponatremia/SIadh now resolved, afib-also now
resolved in NSR, and high grade MSSA bacteremia with current
work-up ongoing for possible localizing source
.
1)Infectious Disease: On transfer to medical service on [**2-3**],
patient with high grade bacteremia-MSSA since [**1-23**]-still
positive on [**1-29**], switched from vanc to ox on [**1-27**], TEE
negative. Because of high grade bacteremia, surveillance
cultures were sent on [**1-15**], [**2-4**] and were all negative.
Additionally, patient underwent chest x-ray on [**2-2**] then CT of
chest on [**2-3**] which showed multiple septic embolic presumed
secondary to MSSA bacteremia. Given negative TEE, other sources
were investigated as possible source. Patient subsequently
underwent CT abdomen which showed no abdominal source, WBC scan
which showed some enhanced uptake in right anterior skull.
Neurosurgery reviewed study and does not feel there is
indication for drainage. MR/MRA of head was then done to better
assess this area and showed no specific abnormalities. Of note,
that patient has been afebrile throughout this time, with
negative surveillance cultures and is without change in
symptomatology or neuro exam. Given that he has had no clinical
neurologic change and has been afebrile throughout this time
with negative surveillance cultures, in consultation with ID and
neurosurgery, medicine team does ot feel as though patient has
mycotic aneurysm or other concerning fluid collection/source of
infection that warrants intervention at this time.
The patient was continued on IV oxacillin and will receive 6
weeks starting from [**2-2**] which is the first day of negative
cultures. Additionally, will need ID follow-up, along with
weekl lft's and cbc's to assess for oxacillin toxicity. As
further work-up for other possible sources and to complete basic
ID work-up, urine, c. diff, stool, o and p studies were sent and
all returned negative.
Additinoally, patient was treated for a separate pneumonia: He
received a seven day course of clindamycin/cipro.
2)cardiac: ischemia: Patient was maintained on aspirin for
primary prophylaxis.
pump: low nl ef, pfo, some evid of fluid by chest CT, no
vegetations by TEE. Attempt was kept to maintain patient
euvolemic, and patient maintained on metoprolol.
rhythm: Patient had episode of afib before transfter to
medicine. He was in NSR while on the medicine service. A fib
was felt likely 2nd to incre adrenergic tone with intracranial
process. He was maintained on metoprolol. Decision was made
not to anti-coag given risk for brain bleed.
3) renal: hyponatremia attributed to SIADH--Patient was
continued on fluid restriction and remained normo-natremic
throughout his stay on the medicine service.
4)GI: Patient with elevated LFT's on transfer, felt possibly [**1-7**]
oxacillin. LFT's were normal on discharge (from [**2-10**]). Will
need to be monitored on oxacillin.
Also with some diarrhea which was improving on discharge. Says
he had some diarrhea before coming to hospital. Sent stool
studies, o and p (wife with history of parasitic infection-works
with handicapped children), and repeated c. diff which were all
negative.
Nutrition: Patient had poor PO intake throughout hospital
course. He says that this is his baseline and as a truck driver
he just doesn't eat much. Nutrition recommended consideration
of g-tube or ng tube but patient did not desire and medical team
felt that given patient has ability to eat and no cause for his
poor intake other than his usual habits, did not place ng tube.
We have provided extensive education, encouragement and he has
been followed by nutrition.
5)neuro: Patient had no major neurologic issues while on the
medicine service. He was followed by neurosurgery. No
neurologic changes noted. Mental status continues to progress
to baseline. Left subdural/epidural collection has
significantly diminished in size.
6)Patient maintained on heparin subcu and famotidine for DVT and
GI prophylaxis respectively.
Patient had PICC line placed on [**2-9**] for IV antibiotic course.
Full code throughout this admission.
Chief Complaint:
see d/c summary
Major Surgical or Invasive Procedure:
see d/c summary
History of Present Illness:
see d/c summary
Past Medical History:
see d/c summary
Social History:
see d/c summary
Family History:
see d/c summary
Physical Exam:
see d/c summary
Pertinent Results:
see d/c summary
Micro:blood
[**Date range (1) 10869**] MSSA
2/24-6/6MSSA
[**2-2**], [**2-3**], [**2-4**] negative
Urine: [**1-23**] enterobacter aerogenes 10-100,000
[**2-1**] and [**2-4**] negative
stool: [**2-8**] negative, also o and p negative
c. diff: [**1-30**] and [**2-8**] negative
[**2-2**] TEE:
1. The left atrium is normal in size. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest.
2.Left ventricular wall thicknesses are normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
5.There are three aortic valve leaflets. Mild (1+) aortic
regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
7.There is no pericardial effusion.
[**2-3**] chest ct:CT CHEST FOLLOWING IV CONTRAST:
There are slightly enlarged right hilar and precarinal lymph
nodes. There is
no pericardial effusion. The heart size is at the upper limits
of normal.
There are bilateral pleural effusions, right greater than left.
Multiple
nodules are seen predominantly within the right lung. Several
are cavitated.
Additionally, there are diffuse peripheral ground-glass
opacities bilaterally.
There is a moderate amount of compressive atelectasis at the
right base. There
is opacity at the left base out of proportion to the adjacent
effusion. No
suspicious lesions are seen within the bones. There is a left
exophytic renal
cyst. A granuloma is seen within the liver.
Within segment 6 of the liver is a 1 cm area of abnormal
enhancement with
smooth margins. There is early filling of an adhacent segment of
hepatic
vein. This suggests a portal/hepatic venous fistuliza or
vascular lesion with
shunting. Has the patient had biopsy or instrumentation in this
region? This
area could be further assessed with ultrasound or MRI if
indicated
IMPRESSION:
1) Cavitary and noncavitary nodules, which are highly suggesive
of septic
emboli in this patient with history of staph bacteremia.
2) Evidence of a vascular lesion in the right posterior liver
(segment VI).
Correlation with ultrasound may be helpful for further
characterization.
[**2-3**] CT abdomen:CT OF THE ABDOMEN WITH ORAL AND IV CONTRAST:
There are small bilateral
pleural effusions with associated atelectasis. The liver,
gallbladder,
spleen, and pancreas are unremarkable. The kidneys and adrenal
glands are
within normal limits with the exception of a simple cyst in the
lower pole of
the right kidney which measures 1.7 x 2.0 cm. The stomach and
opacified loops
of small bowel are of unremarkable appearance. There is a small
hiatal
hernia. There is no free fluid in the abdomen. There is no free
air in the
abdomen. There is diverticular disease without evidence of
diverticulitis. No
intra-abdominal abscess was identified. The appendix was not
identified, but
there is no evidence of appendicitis. There are multiple
mesenteric small
lymph nodes that do not meet CT criteria for pathology. There
are no
significant retroperitoneal lymph nodes.
CT OF THE PELVIS WITH ORAL AND IV CONTRAST: There is
diverticular disease of
the sigmoid colon without evidence of diverticulitis. The
opacified
intrapelvic bowel loops are unremarkable. The distal ureters and
urinary
bladder are unremarkable. The prostate is unremarkable. There is
no free
fluid or free air in the pelvis.
BONE WINDOWS: There is a mild left convex scoliosis. There are
degenerative
changes of the lumbar spine. There are no suspicious lytic or
blastic
lesions.
IMPRESSION:
1. No intra-abdominal source for MSSA bacteremia was identified.
2. Small bilateral pleural effusions.
3. Atelectasis vs pneumonia in the lung bases.
[**2-6**] WBC scan:
INTERPRETATION: Following the injection of autologous white
blood cells labeled
with Indium-111, images of the whole body, wrists and skull were
obtained at 24
hours. These images show increased tracer uptake within the
right lateral
frontal skull and parts of the overlying soft tissues. On the
static images of
the wrist, there is a small focus of increased tracer activity
in the right
wrist. This is rather subtle. No other areas of abnormal tracer
uptake are
identified.
The above findings are consistent with infection in the right
frontal and
lateral skull. There is also possibly a small focus of infection
within the
right wrist.
IMPRESSION: Uptake of radiolabeled white blood cells within the
right anterior
skull. There is also a subtle increased uptake in the right
wrist. These are
consistent with infections in these sites.
/nkg
3/5MR/MRA
BRAIN MRI:
On the diffusion images, no evidence of acute infarct is seen.
There is a
left frontal extra-axial hematoma identified with mixed signal
intensities.
Postoperative changes are seen in this region with craniotomy
for aneurysm
clipping. Artifacts are seen in the left supraclinoid region and
projected
over the left temporal lobe secondary to aneurysm clipping.
There is no
midline shift, mass effect or hydrocephalus seen. Small amount
of blood
products are seen in the subarachnoid space and along the sulci
at convexity.
Following gadolinium administration, there is no evidence of
abnormal
parenchymal, vascular or meningeal enhancement seen. There are
no signs of
cerebritis or cerebral abscess. There is also no significant
enhancement seen
along the left frontal extra-axial collection.
IMPRESSION: Status post aneurysm clipping. No evidence of acute
infarct.
Left frontal extra-axial collection due to hematoma as on the CT
of [**2133-1-24**].
No abnormal enhancement seen.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal in the right
carotid circulation
and in the posterior circulation. The flow signal in the left
middle cerebral
artery is not visualized, which most likely secondary to
artifacts from the
adjacent aneurysm clip. Subtle flow signal is identified in the
branches of
the left sylvian fissure indicating perfusion in this region.
IMPRESSION: Proximal left middle cerebral artery flow signal is
obscured by
artifact from adjacent clips. No other abnormalities. It should
be noted
that the MRA examination is not a sensitive method for
evaluation for mycotic
aneurysm.
Brief Hospital Course:
see d/c summary
Medications on Admission:
see d/c summary
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-7**]
Puffs Inhalation Q4H (every 4 hours) as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for h/o EtOH.
11. Oxacillin Sodium 10 g Recon Soln Sig: Two (2) grams
Injection Q4H (every 4 hours) for 34 days: 6 weeks from [**2-2**], so
will receive for 42 days-continue until [**3-16**].
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Sachem Skilled Nursing & Rehabilitation - [**Location 10870**]
Discharge Diagnosis:
Intracerebral Aneurysms s/p clipping
Cerebral salt wasting (hyponatremia)
Bacteremia, high grade, TEE neg for endocarditis
Aspiration pneumonia
UTI, enterobacter
Discharge Condition:
Stable
Discharge Instructions:
Please call if you have headache or any other pain that does not
respond to pain medication. Call if you develop any sudden
weakness or mental status change. Call if you have a
fever/chills/sweats, or for significant change in bowel
movements.
Take all medications as prescribed.
Follow-up as below.
You will need weekly lab testing.
Followup Instructions:
1. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8257**]. [**Street Address(2) 10871**], [**Hospital1 328**], [**Numeric Identifier 10872**] - ([**Telephone/Fax (1) 10873**]
[**2133-2-23**]. 1:00 pm. Please note that Dr. [**Last Name (STitle) 8257**] will set
you up for follow-up with an infectious disease doctor.
2. Follow up Chest Ct with and without contrat. [**Hospital Ward Name **]
building, [**Location (un) 4875**]. [**2133-2-16**] ;12:45 pm. Do not eat
anything after 10 am on the day of your appointment. You may
drink water and you should take your medication.
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**] MD [**MD Number(1) 628**]
Completed by:[**2133-2-10**]
|
[
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"599.0",
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"682.3",
"401.9",
"378.51",
"V09.0",
"444.9",
"997.3",
"996.62",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"38.93",
"39.52",
"88.72",
"39.51",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
21533, 21622
|
20323, 20340
|
13726, 13743
|
21827, 21835
|
13944, 19672
|
22217, 22973
|
13876, 13893
|
20406, 21510
|
21643, 21806
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20366, 20383
|
1411, 4885
|
21859, 22194
|
13908, 13925
|
5190, 13654
|
13671, 13688
|
13771, 13788
|
19690, 20300
|
13810, 13827
|
13843, 13860
|
5169, 5178
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,812
| 150,512
|
22209+57287
|
Discharge summary
|
report+addendum
|
Admission Date: [**2148-7-3**] Discharge Date: [**2148-7-11**]
Date of Birth: [**2101-10-18**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Abdominal pain/ SOB
Major Surgical or Invasive Procedure:
Debridement of heel wound
History of Present Illness:
46 yo f w/ end stage Etoh cirrhosis w/ recent admit [**2148-6-4**] at
OSH for cirrhosis, [**Month (only) **] bp, acidosis, w/ inc SOB, hypotension,
and BRBPR at NH. Pt found to be encephalopathic. States she has
abd pain and SOB x 3months. Denies hematemesis. In ed 77/58 w/
leukocytosis. Dx'd w/ sepsis. Rec'd Levo/Flagyl and IVF, and
transferred to ICU for further care.
Past Medical History:
Etoh
Cirrhosis
Appendectomy
TAH/BSO
Social History:
Still drinking heavily
Smoker
Family History:
Unknown
Physical Exam:
t98.6, bp 92/52, p65, r 13, 90%RA
jaundice, short of breath
icteric
Regular S1, S2. no m/r/g
LCAb/l
Abd distended. pos bs. pos fluid wv
ext trace edema
asterixis.
a and o x1
Pertinent Results:
na 137, k5.1, cl 115, hco3 11, bun 26, cr .6, inr 2.1 ptt 20.1,
wbcc 18.1 lshift, hct 40.8, plt 66, alt 39, ast 73, lip 72,
amylase 113.
[**2148-7-3**] 11:28PM HCT-31.9*
[**2148-7-3**] 11:28PM HCT-31.9*
Brief Hospital Course:
Pt was admitted to ICU and ruled out for SBP. Found to have
perirectal abscess which was pos for VRE, BxCx coag pos staph.
Rec'd cipro (px dose) and vanc. despite abx, rising WBCC and
[**Last Name (un) **] hypotension/encephalopathy. Changed to CMO on [**7-8**]
followidn discussion w/ family.
Transferred to medical floor for comfort measures. Maintained
on MSO4 titrated to pt comfort. Vitals and labs dc'd. Pt
remained alert but disoriented on floor. Initially maintained
on vanco but pain w/infusion and subsequent attempts to obtain
access resulted in d/c the abx. On [**7-11**] transferred to hospice
facility.
Medications on Admission:
Aldactone 25mg [**Hospital1 **]
Lactulose 20cc [**Hospital1 **]
Protonix 40mg qd
Prednisone 40mg qd
Neomycin 500mg [**Hospital1 **]
Lasix 40mg po qd
Discharge Medications:
1. Morphine Sulfate 20 mg/mL Solution Sig: 10-20 mg PO Q1-2H ()
as needed for pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
End stage liver disease secondary to alcohol. Polymicrobial
sepsis, hypotension. Sacral ulcer.
Discharge Condition:
poor
Discharge Instructions:
Comfort measures only
Followup Instructions:
Follow up with your primary care doctor.
Name: [**Known lastname 6546**],[**Known firstname 779**] Unit No: [**Numeric Identifier 10757**]
Admission Date: [**2148-7-3**] Discharge Date: [**2148-7-11**]
Date of Birth: [**2101-10-18**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 342**]
Chief Complaint:
N/A
Major Surgical or Invasive Procedure:
N/A
Brief Hospital Course:
On [**7-11**], pt was examined in the morning and noted to be in mild
respiratory distress. At the time, she was found to have a
palpable radial pulse but was breathing at a respiratory rate of
8, w/ accesory muscle use and paradoxical abdominal movement.
No interventions were undertaken at that time secondary to the
patient's status as "Comfort Measures Only". Transfer to
hospice was cancelled due to the rapid deterioration in the
patient's condition. At 12:30 pm, I was called to evaluate the
patient, as she was found with no detectable vitals signs. On
exam the pt had fixed and dilated pupils, no palpable carotid
pulse, and no appreciable heart or lung sounds. She was
pronounced deceased at 12:45 pm on [**7-11**] in the presence of
her family, including her health care proxy. The attending
physician was notified.
Please ignore the disposition as "extended care" notation at the
bottom of this note. I was not allowed to alter it by the order
entry system.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Sepsis
Discharge Condition:
Deceased
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 347**] MD [**MD Number(1) 348**]
Completed by:[**2148-7-11**]
|
[
"566",
"276.2",
"995.92",
"038.19",
"572.2",
"038.0",
"286.7",
"571.2",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"38.91",
"54.91",
"48.82",
"48.81"
] |
icd9pcs
|
[
[
[]
]
] |
4018, 4033
|
3016, 3995
|
2988, 2993
|
4083, 4248
|
1105, 1314
|
2507, 2928
|
886, 895
|
2166, 2252
|
4054, 4062
|
1993, 2143
|
2461, 2484
|
910, 1086
|
2945, 2950
|
385, 763
|
785, 822
|
838, 870
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,827
| 137,430
|
42607
|
Discharge summary
|
report
|
Admission Date: [**2169-12-28**] Discharge Date: [**2170-1-9**]
Date of Birth: [**2098-3-23**] Sex: F
Service: SURGERY
Allergies:
epinephrine
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
[**2170-1-2**] [**Doctor Last Name 3379**] colostomy
Vac dressing placed [**1-4**]
History of Present Illness:
Ms. [**Known lastname **] is a 71 year old female with previous medical
history significant for DM2, HTN/HL, and diverticulosis. She
initially presented to [**Hospital6 19155**] on [**12-27**] with 3
weeks of crampy abdominal pain. Initial pain control with
Dilaudid and nausea control with Zofran + Reglan. CT abdomen
showed ?diverticular abscess and he was started on
Levaquin/Flagyl initially. She had a leukocytosis to 25 and
hypotension requiring neosyneprhine. Given her worsening
picture, she was brought to the OR for an exploratory
laparotomy.
.
A necrotic uterus was found and Ob-Gyn was called in for a
sub-total hysterectomy and bilateral salpingo-oopherectomy and
omentectomy were performed. They found a pocket of pus/abscess
adjacent to uterus (walled off). No fistula, no diverticulitis.
Omentectomy done "just in case it was cancer". They closed the
fascia, placed a JP, left SQ tissue open. She was given FFP and
10mg vitamin K IV intra-op for an INR of 1.6-->1.4.
Peri-operative EBL~500cc and follow-up hematocrit went from 26
to 24. She no longer required pressors post-operatively, but
remained intubated due desaturation to 85% on 4L, corrected to
100% on NRB presumably secondary to pulmonary edema (confirmed
by CXR) so she was given lasix 100mg IV with 1650cc output.
Prior to transfer, she was reportedly given 1 unit pRBCs
followed by Lasix. Antibiotic coverage broadened with
Zosyn/Flagyl/Levaquin with blood cultures growing GNRs and GPCs
in [**4-17**] bottles and GNRs in urine culture. An arterial line is
in place with a right double-lumen PICC. She was sedated on
propofol. She has a partially open abdomen, packed with
betadine/gauze and with a JP drain in place (drained 20cc of
serosanguinous fluid to date).
.
On arrival to the MICU, she was breathing spontaneously on
pressure support and ABG showed 7.37/37/152. She was in
significant pain, so she was bolused with Fentanyl for comfort
and started back on AC for rest.
.
Review of systems: Unable to perform secondary to sedation
Past Medical History:
type 2 diabetes mellitus
- HTN (diagnosed in [**2164**])
- HL
- diverticulosis
- right hydronephrosis on CT abdomen in [**2164**], ?etiology
- s/p carpal tunnel release
- "disc surgery"
- tubal ligation
Social History:
Lives independently in [**Location (un) **]
- Tobacco: none
- Alcohol: none
- Illicits: none
Family History:
No reported history of cancers, blood disorders, or GU issues.
Mother had breast "lump". One of her daughter had a
hysterectomy for unknown reasons.
Physical Exam:
Admission PE:
Vitals: T: 97.7, BP: 93/50, P: 93/50, R: 15 O2: 86% on PS [**10-23**]
General: opens eyes to voice, sleepy
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Relatively clear to auscultation bilaterally, no wheezes,
rales, rhonchi
Abdomen: protuberant, soft, diffusely tender with
vertically-sutured wound packed with gauze and abdominal binder
in place. Bowel sounds quiet, no organomegaly appreciated
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, [**1-15**]+ edema
Neuro: opens eyes to voice, painful to palpation of abdomen
Pertinent Results:
Admission Labs:
[**2169-12-28**] 09:00PM BLOOD WBC-15.0* RBC-3.11* Hgb-9.3* Hct-28.3*
MCV-91 MCH-29.8 MCHC-32.7 RDW-13.7 Plt Ct-164
[**2169-12-28**] 09:00PM BLOOD Neuts-82* Bands-8* Lymphs-7* Monos-1*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2169-12-28**] 09:00PM BLOOD PT-18.5* PTT-31.3 INR(PT)-1.7*
[**2169-12-29**] 03:24AM BLOOD PT-16.6* PTT-28.2 INR(PT)-1.6*
[**2169-12-28**] 09:00PM BLOOD Glucose-143* UreaN-52* Creat-2.4* Na-140
K-4.6 Cl-109* HCO3-20* AnGap-16
[**2169-12-29**] 03:24AM BLOOD Glucose-85 UreaN-55* Creat-2.5* Na-141
K-4.2 Cl-108 HCO3-23 AnGap-14
[**2169-12-29**] 04:27PM BLOOD Glucose-67* UreaN-51* Creat-2.2* Na-145
K-4.0 Cl-109* HCO3-27 AnGap-13
[**2169-12-30**] 04:02AM BLOOD ALT-45* AST-77* LD(LDH)-312* AlkPhos-141*
TotBili-0.9
[**2169-12-28**] 09:00PM BLOOD Calcium-7.2* Phos-4.6* Mg-1.9
[**2169-12-29**] 03:24AM BLOOD Calcium-7.8* Phos-4.7* Mg-1.9
[**2169-12-29**] 03:24AM BLOOD CEA-1.9 CA125-50*
[**2169-12-28**] 09:07PM BLOOD Lactate-2.2*
[**2169-12-29**] 03:42AM BLOOD Lactate-1.3
[**2169-12-29**] 12:20PM BLOOD Lactate-1.4 K-4.2
[**2169-12-28**] 09:07PM BLOOD freeCa-0.99*
[**2169-12-29**] 03:42AM BLOOD freeCa-1.07*
[**2170-1-1**]: Blood-bank:
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Ms. [**Known lastname **] has a
confirmed
diagnosis of Anti-D antibody. D-antigen is a member of the
Rhesus blood
group system. Anti-D antibody is clinically significant and
capable of
causing hemolytic transfusion reactions.
In the future, Ms. [**Known lastname **] should receive D-antigen negative
products
for all red cell transfusions. Approximately 15% of ABO
compatible blood
will be D-antigen negative.
[**2169-12-28**]: EKG:
Probable ectopic atrial rhythm. Slight upsloping ST segment
elevation in
lead aVF which does not meet diagnostic criteria for myocardial
infarction.
Low amplitude QRS voltage in the limb leads and precordial
leads. No previous tracing available for comparison.
[**2169-12-29**]: ECHO:
IMPRESSION: No valvular vegetations seen. Mild mitral
regurgitation. Normal global and regional biventricular systolic
function
[**2169-12-31**]: cat scan of the head:
IMPRESSION: No acute intracranial process.
[**2169-12-31**]: chest x-ray:
Still mild-to-moderate pulmonary edema has markedly improved. NG
tube tip is out of view below the diaphragm. Cardiomediastinal
contours areunchanged.
There is no pneumothorax. If any, there is a small left pleural
effusion.
[**2170-1-1**]: ekg:
Sinus rhythm. Possible inferior myocardial infarction.
Borderline low voltage.
Since the previous tracing of [**2169-12-28**] there is probably no
significant
change
[**2170-1-1**]: chest x-ray:
IMPRESSION: Retrocardiac atelectasis and improving pulmonary
edema with small left pleural effusion.
[**2170-1-1**]: chest x-ray:
IMPRESSION: Right PICC tip in the right atrium, retraction by 5
cm should be considered
[**2170-1-1**]: chest x-ray:
The ET tube tip is 3.2 cm above the carina. The NG tube tip is
in the
stomach. The right PICC line tip has been adjusted, currently
being at the
level of mid SVC. There is interval improvement of pulmonary
edema. Left
retrocardiac consolidation is still present, most likely
representing
atelectasis, attention to this area is highly recommended to
exclude the
possibility of developing infection. Small amount of pleural
effusion is seen bilaterally. The NG tube tip is in the stomach.
[**2170-1-2**]: chest x-ray:
FINDINGS: In comparison with the study of [**1-1**], the monitoring
and support devices remain in place. Continued opacification in
the retrocardiac region is consistent with atelectasis and
effusion, in the appropriate clinical setting, superimposed
pneumonia would have to be considered. Pulmonary vascularity is
essentially within normal limits.
[**2170-1-4**]: chest x-ray:
FINDINGS: In comparison with the study of [**1-3**], the
endotracheal tube has been removed. Some retrocardiac
opacification persists consistent with volume loss and effusion.
Prominence of pulmonary markings is consistent with elevated
pulmonary venous pressure.
Brief Hospital Course:
71 year old female with history of DM2, HL, and diverticulitis
s/p subtotal hysterectomy and bilateral oopherectomy for a
necrotic uterus and associated abscess, presenting with GNR/GPC
bacteremia concerning for polymicrobial sepsis.
# GNR/GPC sepsis: The patient was admitted to the MICU for
polymicrobial sepsis, initially was on phenylephrine while at
OSH, but on transfer to [**Hospital1 18**], the patient was off pressors. At
OSH, she was s/p hysterectomy and bilateral oopherectomy with
observed walled-off abscess adjacent to a necrotic uterus, with
blood cultures in [**4-17**] bottles with GNRs + GPCs as well as urine
cultures with GNRs. The patient was transferred over on
Levoflox, Flagyl, and Zosyn and on arrival to [**Hospital1 18**], she was
broaded to Vanc/Zosyn. Her a-line and PICC line placed at OSH
were pulled. The patient was bolused cautiously for MAPs <65.
The patient had an elevated white count, which persisted after
starting empiric antibiotics. ID was consulted and they
suggested that her white count was likely lagging and based on
sensitivies from OSH, her abx were changed to
Ceftriaxone/Flagyl. A new PICC line was placed. On transfer
out of the MICU, here pressures were stable in 140-160s
systolic. The patient remained afebrile throughout.
.
# Respiratory failure: Patient was intubated for the OR and
remained intubate post operative; was found to have extensive
pulmonary edema and was started on diuresis on tranfer to the
[**Hospital1 18**]. While in the MICU diueresis was continued and the
patient ultimately self extubated herself. Post extubation, she
was satting in the high 90s on shovel mask.
.
# s/p exlap: Pt had exlap at OSH, found to have disintegrating
uterus, with evidence of ?extrauterine abscess. As per
operative note, the bowel was run and no evidence of perforation
was seen. A JP was placed and the fascia was closed, but the
skin and subcutaneous tissue was left open. On arrival to the
MICU, JP was draining serosanginous fluid. However, a few days
into the hospitalization, the JP started draining feculent
material. Surgery was consulted re: possible fistula and patient
was taken to the OR and then to the SICU postoperatively.
.
# altered mental status: S/p self-extubation, the patient was
altered, lethargic, and not very responsive. Thought likely due
to residual sedatives from being intubated, possibly hypomanic
delirium. A CT head was done to rule out any intracranial
pathology, which was negative for any acute intracranial
process. The patient's mental status continually cleared while
she was in the unit.
.
# Blood pressure: The patient was on neo at OSH, but on arrival
to [**Hospital1 18**], her pressures stabilized. She had some episodes of
hypotension into the low 80s, however, that responded to fluid
boluses. Her home lisinopril was held while in the MICU.
.
# Acute kidney injury: On transfer to [**Hospital1 18**], the patient's creat
up to 2.4, baseline 1.0-1.4. Likely related to hypotension and
possible ATN, but no casts seen on urine sediment. Also could
be related to contrast nephropathy, as pt had CT at OSH. Fena
5.2% consistent with an acute tubular necrosis picture. Her
creat was trended while in the MICU, and on transfer out of the
unit, her urine output was improving and creat trended down to
1.4.
.
# Acute blood loss anemia: Pt was transferred over from OSH with
crit of 24, as per report, received 1U PRBC on transfer. Repeat
crit was 28 and her crits remained stable while she was in the
MICU.
.
# DM2: The patient's home oral hypoglycemics were held in
patient, and she was started on ISS.
# Hyperlipidemia: continue simvastatin
***Surgery consultation was placed [**1-2**] for feculent drainage
from JP drain. On surgical evaluation patient was somnolent
with mild lower abdominal tenderness on physical exam. Despite
this, patient had frank stool from lower abdominal JP drain.
Risks/benefits of surgical intervention were discussed with
patient's family (healthcare proxy). During process of surgical
evaluation patient had aspiration event requiring intubation.
Patient was then taken to operating room for exploratory
laparotomy. Intra-operative findings were consistent with
sigmoid diverticulitis with extensive inflammation. Sigmoid
colon was resected with Hartmann's procedure and washout.
Patient tolerated procedure well and was tranferred to TSICU
intubated/sedated for further management. Remainder of hospital
course as follows:
Neuro: Post-operatively, the patient was left intubated/sedated.
Following extubation, analgesia administered via intermittent
IV narcotics and acetaminophen with good effect and adequate
pain control. Mental status cleared significantly with return to
near baseline (A&Ox3) by POD1. When tolerating oral intake, the
patient was transitioned to oral pain medications.
CV: Patient did not require pressors postop. Had intermittent
hypertension managed w prn hydralazine IV. When tolerating po
intake patient was started on home CV medications. vital signs
were routinely monitored.
Pulmonary: Patient was left intubated postop and successfully
extubated POD1 ([**1-3**]). Supplemental oxygen was weaned
effectively. Pulmonary toilet including incentive spirometry
and early ambulation were encouraged. The patient was stable
from a pulmonary standpoint; vital signs were routinely
monitored.
GI/GU: Post-operatively, the patient was NPO w IVF hydration and
NGT. NGT removed [**1-4**] w positive gas and stool per ostomy.
Her diet was advanced to sips [**1-4**], regular diet [**1-5**], which
was tolerated well. She was also started on a bowel regimen to
encourage bowel movement. JP drain was removed [**1-5**] as output
decreased to less than 30cc/day.
Lower midline abdominal wound had been left open to close by
secondary intention following initial OSH surgery. Lower
midline was used for Hartmann's and left open to close by
secondary intention. With wound base clean and fascia intact,
vac was placed [**1-4**]. This was changed at 3 day intervals with
good result and healthy granulation tissue seen to be forming.
Patient had manifested [**Last Name (un) **] w creatinine bump as per above. This
returned to [**Location 213**] as patient recovered. Foley was removed on
[**1-5**] and patient voided appropriately. Intake and output were
closely monitored.
ID: At time of transfer from medical service patient was on
CTX/flagyl per ID recs. Leukocytosis and fever curve were
followed. Intra-operative findings and persistent leukocytosis
prompted switch to vanco/zosyn per ID [**1-3**]. This was continued
until [**1-8**]. All BCx at [**Hospital1 18**] were returned negative as of this
report.
HEME: Patient admitted with baseline anemia from OSH.
Postoperatively hct drifted from 25-28 range to low 20s though
no bleeding source suspected. Transfused 1u pRBC [**1-5**] and 25 w
appropriate bump in hct. Hct was trended and found to be stable
following this.
ENDO: Insulin sliding scale was utilized for glucose control
postop with good effect. Transitioned to home po regimen when
tolerating po.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
DISPO: Patient evaluated by PT who recommended dispo to rehab
for continued recovery. This was arranged and patient prepared
for d/c [**1-9**].
At the time of discharge on [**1-9**], the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating w assistance, voiding without assistance, and pain
was well controlled.
Medications on Admission:
[**Last Name (un) 1724**]: Lisinopril 10', Glyburide 5 qAM, 2.5mg qPM, Metformin
1000'', Fish Oil 300'', Glucosamine-chondroitin 1', Simvastatin
40'
Discharge Medications:
1. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. glyburide 5 mg Tablet Sig: One (1) Tablet PO MORNING ().
4. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO EVENING ().
5. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
sepsis
perforated diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you had an exploratory
lapartomy for a ? ruptured uterus. You developed an abscess
near your surgery site and became very ill. You were
transferred here for further managment. You were takne to the
operating room where you found to have a perforated
diverticulitis with pelvic peritonitis. You had a section of
your colon resected and had a colostomy placed. You are slowly
getting better. You vital signs are stable and your white blood
cell count is decreasing. You are now on intravenous
antibiotics. You had a special dressing called a VAC dressing
over the incision to help with wound healing. You are now
preparing for discharge.
Completed by:[**2170-1-9**]
|
[
"285.1",
"785.52",
"507.0",
"567.22",
"614.5",
"599.0",
"518.4",
"250.00",
"041.49",
"569.5",
"272.4",
"562.11",
"401.9",
"041.02",
"038.42",
"995.92",
"780.09",
"V88.01",
"584.5",
"615.0",
"288.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93",
"45.75",
"46.10",
"54.25",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15999, 16046
|
7755, 9979
|
278, 363
|
16123, 16123
|
3658, 3658
|
2779, 2931
|
15580, 15976
|
16067, 16102
|
15405, 15557
|
16274, 16985
|
2946, 3639
|
2382, 2424
|
232, 240
|
391, 2363
|
3675, 7732
|
16138, 16250
|
2447, 2652
|
2668, 2763
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,913
| 145,561
|
24058
|
Discharge summary
|
report
|
Admission Date: [**2153-8-29**] Discharge Date: [**2153-8-30**]
Date of Birth: [**2103-2-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
elective ASD closure
Major Surgical or Invasive Procedure:
ASD closure
History of Present Illness:
50 year old Cantonese speaking male with no cardiac history,
found to have an ASD that is now s/p closure with amplatz device
on [**2153-8-29**], admitted to the CCU for post-procedure monitoring. He
reported a history of dyspnea for the last year, as well as
chest pain over the last 6 months. CT and echo demonstrated a
large ASD with dilated RV and moderate dilation of RA and LA.
PA pressures were reported to be normal. On [**2153-8-17**] the patient
underwent cardiac catheterization. He was found to have normal
coronary arteries, an RA of 6 mmHG, RV of 25/7 mmHG, PA pressure
of 25/10 mmHG, mean PA pressure of 17 mmHG, wedge of 10 mmHG.
O2 sat measurements were consistent with left to right shunting.
He was admitted this AM for elective ASD closure with 3D TEE
guidance.
.
His procedure this AM was relatively uncomplicated, however the
closure device was difficult to seat in the septal defect, so
there was some concern for possible migration or embolization
with valsalva or other large changes in pressure. He is
therefore admitted to the CCU for post-procedure monitoring.
.
On arrival to the floor, patient is extubated but very sleepy
and frequently apneic. He denies pain or discomfort.
Past Medical History:
- ASD now s/p closure with Amplatzer device [**2153-8-29**]
- Anxiety disorder
- ? Prostate issue
Social History:
Divorced, no children. Works full time as chef. No tobacco, no
ETOH, no drugs
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father passed
away from liver cancer
Physical Exam:
VS: afebrile
GENERAL: Appears well. Tired and sleepy.
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits. No bluish toes or
signs of emboli.
SKIN: No stasis dermatitis, ulcers, scars. Cath site appears
clean, dry and intact.
PULSES:
Right: Carotid Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs:
[**2153-8-30**] 05:04AM BLOOD Hct-39.2* Plt Ct-197
[**2153-8-30**] 05:04AM BLOOD UreaN-16 Creat-0.8 Na-139 K-3.3 Cl-106
[**2153-8-30**] 05:04AM BLOOD CK-MB-5
TTE: [**2153-8-30**]:
A septal occluder device is seen across the interatrial septum.
The device abuts the aortic root on both sides, but does not
directly imponge on it. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
mild global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
.
IMPRESSION: Atrial septal occluder in place without significant
residual flow by color Doppler. Trace aortic regurgitation.
Brief Hospital Course:
50 year old Cantonese speaking male with no cardiac history,
found to have an ASD that is now s/p closure with amplatzer
device on [**2153-8-29**] without any complcations.
.
# ASD Closure: Patient had symtpoms of shortness of breath and
chest discomfort for the past 6 months. TTE and CT chest showed
dilated RV and RA, a large secundum ASD (2.1 cm. Cath showed no
angiographically CAD, his right sided pressures were normal with
Qp/Qs of 2.4, therefore he was considered a good candicate for
ASD closure. Patient had closure of ASD with amplatzer device
without any complcaitions however closure device was difficult
to seat in the septal defect therefore he was admitted for
monitoring in the CCU. During his short CCU stay patient did
not have any chest pain, shortness of breath or any other
symptoms. His cath site remained clean and dry without any
bleeding. He did however have occasional central apnea during
sleep right after being extubated which resolved after few
hours. Follow up TTE showed the amplazter device in place
without any shunting. During this hospitalization he was
started on aspirin x1 year and plavix x 3 months. He was also
adviced to avoid any heavy lifting for the next 3 months to
prevent displamcement of the closure device.
.
CODE: Full Code
.
Transition of Care:
- No labs pending
- Patient will continue to take Aspirin 325mg daily for one
year.
- Patient will continue to take plavix 75mg daily for 3 months.
- Patient will avoid any heavy lifting or rigorous activity for
at least three weeks.
- Patient will follow up with PCP for [**Name9 (PRE) 35455**] care.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*4
2. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*90
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
atrial septal defect
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You had a
procedure to close the hole in the upper part of the heart.
There were no complications from the procedure. You were
monitored in the cardiac intensive care unit overnight without
any events. You were also started on two medications (aspirin
and plavix) to help in preventing a clot in your new heart
device. You should continue to take aspirin for at least one
year and you should continue to take plavix for 3 months. For
at least three months you should also avoid any heavy lifting
(e.g >20 pounds)or rigourous activity.
Discharge Instructions:
- Continue aspirin 325 mg a day for 1 year.
- Continue plavix 75 mg a day 3 months
- Avoid heavy lifting for at least three months
- Follow up with your primary care physician (see below) for
further care.
Followup Instructions:
Name: [**Name6 (MD) 27839**] [**Name8 (MD) **], MD
Specialty: Primary Care
When: Thursday [**9-6**] at 11:30am
Location: [**Hospital3 8233**]
Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 8236**]
Completed by:[**2153-8-30**]
|
[
"745.5",
"300.00",
"780.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.52"
] |
icd9pcs
|
[
[
[]
]
] |
5532, 5538
|
3607, 5215
|
323, 337
|
5603, 5603
|
2591, 2591
|
6639, 6926
|
1809, 1961
|
5270, 5509
|
5559, 5582
|
5241, 5247
|
6409, 6616
|
1976, 2572
|
263, 285
|
365, 1576
|
2607, 3584
|
5618, 5730
|
1598, 1697
|
1713, 1793
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,271
| 140,955
|
9070
|
Discharge summary
|
report
|
Admission Date: [**2164-11-6**] Discharge Date: [**2164-11-9**]
Date of Birth: [**2089-10-1**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 75 year old man with a history of metastatic
colon cancer now presenting with dizziness. The patient is
Mandarin speaking only and the history was obtained with the
help of a translator and his daughter. According to the patient
he was in his
usual state of health when he woke up the morning of admission
around 6 am.
He ate a breakfast of cereal and while sitting at the table when
he
suddenly began to feel dizzy. He motioned with his hand to
indicate a "spinning" sensation, and he said that the sensation
felt better when he closed his eyes. He felt increased
generalized fatigue and nausea as well. He
subsequently vomited 3x. When he stood to walk he felt very
unsteady. He denied any focal numbness or weakness. His
daughter brought him to the [**Name (NI) **] for further evaluation. In the
ED, he still felt this dizziness and kept his eyes closed during
the interview with the ED neurology resident. He denied any
recent infectious symptoms diarrhea, post-nasal drip, or rashes.
He did not feel any lightheadedness with the symptoms, and
denied any new visual symptoms. Of note, he is blind in his
right eye, the result of glaucoma.
Past Medical History:
-Colon cancer status post 5-FU and leucovorin [**1-16**] and status
post liver right lobectomy for three liver mets in [**1-17**],
complicated by a bile leak with catheter removal in [**11-16**],
persistent sinus tract drainage from the site.
-CAD s/p MI
-Hypercholesterolemia
-HTN x 10 years
-Glaucoma resulting in right eye blindness. Both eyes were
operated on at some point.
Social History:
He lives with his wife and daughter; he neither smokes nor
drinks
alcohol. He formerly worked as a cook.
Family History:
There are no strokes or neurological disorders in the family.
Physical Exam:
Gen: fatigued appearing, older Asian male, NAD
HEENT: clear op, MMM
Neck: no bruits
CV: regular, no murmurs
Pulm: CTA anterior/laterally
Abd: soft, NT +BS
Ext: warm, no edema, good pulse right radial/brachial; weak
pulse on left radial/brachial.
Skin: abdominal scars
Neuro:
Mental status: Mandarin speaking only, exam performed with
daughter as
translator. Alert to self and place. Somewhat sleepy but
arousable
to voice. Follows one and two-step commands. Language difficult
to assess but no report by daughter of slurred speech or errors.
CN: I--not tested; II,III-RIGHT pupil dilated with scarring,
LEFT pupil [**3-14**] but also post-surgical; fundi difficult to
visualize in either eye due to scarring. Right eye blind. Left
VFF.
III,IV,VI-EOMI w/o nystagmus however there is
evidence of saccadic intrusion bilaterally, no ptosis; when
later assessed there is some nystagmus on right lateral gaze
with fast component to right. V--
sensation intact to LT/PP, masseters strong symmetrically;
VII-no
facial asymmetry, muscles of facial expression strong; VIII-not
formally tested; IX,X--voice normal, palate elevates
symmetrically, uvula midline, gag intact; [**Doctor First Name 81**]--SCM/trapezii [**5-17**];
XII--tongue protrudes midline, no atrophy or fasciculation.
Motor: Mild right pronator drift; strong extensors of the arms
and wrists and hand grasps bilaterally; moves legs as well with
nl extensor strength; normal tone in legs.
Coordination: markedly dysmetric finger to nose that is worse on
the left than the right, particularly when touching nose.
Finger to finger is limited by poor vision (patient reaches with
hand out of proportion to distance). Heel to shin bilaterally
normal, and toe tapping normal. Marked rebound with overshoot
of left hand compared to right when pushed downward.
Sensory exam on legs "LT intact," and proprioception exam spotty
due to language barrier
DTRs: symmetric and normal throughout, with bilaterally upgoing
toes, although this was not later reproducible.
Gait deferred due to the patient's condition - patient with
marked truncal ataxia sitting at edge of bed.
Pertinent Results:
[**2164-11-6**] 12:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2164-11-6**] 10:50AM GLUCOSE-144* UREA N-19 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-19* ANION GAP-18
[**2164-11-6**] 10:50AM ALT(SGPT)-7 AST(SGOT)-19 LD(LDH)-195
CK(CPK)-48 ALK PHOS-73 AMYLASE-91 TOT BILI-1.0
[**2164-11-6**] 10:50AM LIPASE-45
[**2164-11-6**] 10:50AM CK-MB-NotDone cTropnT-<0.01
[**2164-11-6**] 10:50AM ALBUMIN-4.3
[**2164-11-6**] 10:50AM CHOLEST-193
[**2164-11-6**] 10:50AM TRIGLYCER-120 HDL CHOL-51 CHOL/HDL-3.8
LDL(CALC)-118
[**2164-11-6**] 10:50AM PT-13.1 PTT-23.7 INR(PT)-1.1
[**2164-11-6**] 10:20AM WBC-8.5 RBC-5.27 HGB-16.2 HCT-49.6 MCV-94
MCH-30.8 MCHC-32.7 RDW-14.1
[**2164-11-6**] 10:20AM PLT COUNT-212
BRAIN MRI [**11-6**]:
"IMPRESSION:
1. There is no evidence of a brain metastasis.
2. The appearance of the left cerebellar lesion described on CT
of the same
day is consistent with a recent infarct within the left superior
cerebellar
artery territory.
3. There are 2 additional old infarcts in the cerebellum, one
with vague associated enhancement, which is typically seen in
infarcts that date between several weeks and several months
old."
CT BRAIN:
"IMPRESSION:
1. Slight increase in hypodensity of a left cerebellar infarct,
with mild increase in local mass effect upon the quadrigeminal
cistern, without evidence of acute intracranial hemorrhage.
2. Stable appearance of probable prior infarcts within the right
and left cerebellar hemispheres."
ECHOCARDIOGRAM:
1. The left atrium is mildly dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%).
3.Right ventricular chamber size and free wall motion are
normal.
4.The aortic valve leaflets are mildly thickened. Mild (1+)
aortic regurgitation is seen.
5.The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
6.There is no pericardial effusion.
IMPRESSION:
No cardiac source of embolus seen.
CAROTID STUDIES:
Official read pending; prelim, L ICA 40-59%; L int carotid <40%;
L vert thin with "pre-subclavian steal"
MRI/MRA on the day of discharge ([**11-9**])
Comparison is made to the prior MRI of [**2164-11-6**] and a CT scan
of [**2164-11-7**].
There has been no further progression of the area of left
cerebellar
infarction. Fourth ventricle remains patent and the lateral and
third
ventricles are not dilated. Additional small areas of signal
abnormality in the cerebellum are stable. No new areas of
diffusion signal abnormality are seen. MRA of the circle of
[**Location (un) 431**] is somewhat limited by motion artifact. There is flow in
both internal carotid arteries and in the anterior and middle
cerebral arterial branches. The left intracranial vertebral
artery is not identified. The right vertebral artery continues
as the basilar artery. There is flow signal observed within both
posterior cerebral arteries. A left posterior communicating
artery or fetal origin of the posterior cerebral artery is also
identified.
IMPRESSION:
1. MRI of the brain reveals no change in the extent of left
cerebellar
infarction and no new findings.
2. MRA of the circle of [**Location (un) 431**] is limited by motion artifact,
but there is
flow in the anterior circulation, right vertebral artery,
basilar artery, and posterior cerebral arteries. The left
vertebral artery is not identified and is likely stenosed or
occluded.
Brief Hospital Course:
75 yo man with hx colon ca and the following stroke RFs: CAD s/p
MI, High Chol, HTN, age, with ?hypercoagulablility from GI
malignancy?, who presented with dizziness, nausea and vomiting,
found to have dysmetria on exam, and by CT, acute left
cerebellar stroke that seemed to be in the left SCA territory;
he has other older strokes in the cerebellum bilaterally, and
thus seemed likely to have a posterior
circulation defect. By MRI, he did not seem to have metastatic
disease in his brain.
The head of his bed was kept down for the first twenty-four
hours to maximize cerebral bloodflow and minimize symptoms, and
his blood pressure was allowed to autoregulate. He was
monitored in the ICU for first 24 hours of admission, and once
felt to be stable, he was transferred to the floor. For his
borderline lipid panel, we started a statin (Lipitor 20 mg);
LFTs should be monitored, as he has a history of liver
metastases status post resection. He is now on aspirin 325 mg.
Blood pressure will be monitored carefully. As symptoms improve
(including nausea), diet will be advanced as tolerated. An echo
was unrevealing as a source of emboli, with no wall motion
abnormalities, and in fact, hyperkinetic with an EF of 75%.
Carotid ultrasound report suggested (among 40-59% L carotid
stenosis) a subclavian steal syndrome. MRA of the chest was
considered in addition to intracranial circulation imaging, to
better characterize this question of steal; he was discussed in
vascular neurology conference, and the decision was made not to
pursue this, as he had never had symptoms from the steal before,
and with his other stroke risk factors, this was not likely to
be the cause of his present vascular event. On the floor, he
continued to have some nausea, which was treated with Anzemet.
He also had a guaiac positive stool (which was brown, and
without associated acute anemia by CBC). This should be
monitored, and at his next oncology appointment, this should be
addressed (ie, does he need a follow-up colonoscopy, or CT?) On
telemetry, he was generally regular, but after a brief run of
apparent SVT lasting 4-5 seconds, an EKG was performed that was
completely unchanged from prior (inferior and anterior Q's and
TWIs in lateral leads); lytes were normal. MRA performed on the
day of discharge showed occlusion of the left vertebral, and
unchanged distribution of infarct with no exacerbation of edema.
Because of his posterior circulation disease and his potential
hypercoagulable state (due to malignancy), anticoagulation was
considered with Coumadin. In addition to the fact that evidence
for anticoagulation in this capacity is lacking, he is also
currently very ataxic and thus at great risk for fall; he would
not be a good candidate for this medication. For his history of
a heart attack in the past, he is on a beta blocker, aspirin,
and additionally, for improved blood pressure control, a
low-dose ace inhibitor was added (Lisinopril 5mg). For nausea,
he has been on Anzemet, and could take PO/PR compazine
alternatively. His examination at discharge was notable for
being more awake; he walked with difficulty with his daughters
and gait was quite ataxic. Truncal ataxia was still present,
and finger-nose-finger tasks were still more abnormal on the
left than the right. Regarding his dizziness, he reported
feeling better although not at baseline, and remained nauseous;
he was in good spirits on the day of discharge.
Medications on Admission:
atenolol, timolol, prednisone, allpurinol, methemazole
Discharge Medications:
1. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day): Each Eye [**Hospital1 **].
2. Methazolamide 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold for sbp<100 hr<60.
9. Compazine 10 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Acute Cerebellar Infarction
Acute Cerebellar Infarction
Discharge Condition:
Stable neurological exam, some mild improvement but not at
baseline.
Stable neurological exam, some mild improvement but not at
baseline. Still with truncal ataxia and abnormal finger to nose
on left more than right.
Discharge Instructions:
Mr. [**Known lastname **] has had an acute cerebellar stroke and still feels
dizzy. This should improve with time. If it suddenly worsens,
or if he develops more nausea, new visual disturbances, speech
or language problems, numbness, tingling or weakness, please
notify MD.
Please check LFTs within one month (at rehab or at hm) now that
patient is on lipitor.
Followup Instructions:
Neurology follow-up appointment with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **]
([**Telephone/Fax (1) 7394**]
[**First Name9 (NamePattern2) **] [**2-13**] at 2:15 PM
[**Hospital Ward Name 23**] [**Location (un) **].
Oncology Appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2164-11-12**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2164-11-19**] 10:20
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2164-11-26**] 10:15
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2164-11-9**]
|
[
"781.3",
"365.9",
"369.60",
"414.01",
"434.91",
"412",
"V10.05",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12330, 12409
|
7919, 11373
|
326, 332
|
12509, 12729
|
4302, 7896
|
13141, 13982
|
2076, 2140
|
11479, 12307
|
12430, 12488
|
11399, 11456
|
12753, 13118
|
2155, 2430
|
276, 288
|
360, 1533
|
2445, 4283
|
1555, 1936
|
1952, 2060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,129
| 106,633
|
10027+10028+10029
|
Discharge summary
|
report+report+report
|
Admission Date: [**2111-12-11**] Discharge Date: [**2111-12-17**]
Date of Birth: [**2063-4-17**] Sex: F
Service: Medical Intensive Care Unit/Medicine, [**Hospital1 139**] Firm
CHIEF COMPLAINT: Sepsis.
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
female with an extensive past medical history most notable
for a deep venous thrombosis and pulmonary embolism. The
patient was hospitalized in [**2111-11-21**] while on
Coumadin and an inferior vena cava filter was placed.
The patient presented with one to two days of shortness of
breath, malaise, and nonspecific complaints at her nursing
home. Her temperature there was noted to be 101 degrees
Fahrenheit, and her oxygen saturations were noted to be 88%
on 3 liters via nasal cannula. The patient described chills,
nausea, and vomiting (more so than her baseline). Shortness
of breath, but no production of sputum. No diarrhea. No
constipation. No chest pain. She said she has not been
feeling since she was discharged from her prior admission on
[**2111-11-29**] but got much worse over the last two days.
She also notes weight loss of approximately seven pounds and
poor oral intake.
In the Emergency Department, the patient was found to have a
temperature of 102.3 degrees Fahrenheit, her blood pressure
was in the 80s/60s, and a heart rate of 140. A sepsis
protocol was initiated at this point.
PAST MEDICAL HISTORY:
1. Systemic lupus erythematosus with skin involvement.
2. [**Doctor Last Name 15532**] esophagus/dysphagia.
3. Esophageal strictures.
4. Peripheral neuropathy.
5. Anxiety.
6. Eating disorder 12 years ago.
7. Status post gastric bypass surgery.
8. Deep venous thrombosis and pulmonary embolism on [**2111-11-23**].
9. Hypothyroidism.
MEDICATIONS ON ADMISSION: (Medications on admission were as
follows)
1. Multivitamin one tablet by mouth once per day/
2. Protonix 40 mg by mouth once per day.
3. Synthroid 100 mcg by mouth every day.
4. Remeron 30 mg by mouth once per day.
5. Lactulose 15 mL to 30 mL by mouth at hour of sleep.
6. Colace 100 mg by mouth twice per day.
7. Senna.
8. Calcium carbonate 500 mg by mouth three times per day.
9. Vitamin D.
10. MS Contin 30 mg by mouth twice per day.
11. Lorazepam 0.5 mg by mouth twice per day.
12. Verapamil 40 mg by mouth three times per day.
13. Buspirone 15 mg by mouth three times per day.
14. Morphine sulfate immediate release 15 mg up to three
times per day as needed.
15. Tylenol by mouth as needed.
16. Albuterol as needed.
17. Coumadin 3 mg by mouth once per day.
18. Folate.
19. Vitamin B12.
20. Reglan 10 mg by mouth three times per day.
21. Prednisone 7.5 mg by mouth once per day.
ALLERGIES:
1. PENICILLIN (she gets hives).
2. SULFA (she gets a rash).
3. AZITHROMYCIN (she gets anaphylaxis).
4. OFLOXACIN (she gets anaphylaxis).
SOCIAL HISTORY: The patient lives in the [**Hospital6 13941**]
home. She has smoked half a pack of cigarettes per day for
approximately 40 years. She does not drink alcohol. She
does not use drugs. She gets around in a wheelchair.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed the patient's temperature was 99
degrees Fahrenheit, her blood pressure was 103/62, her heart
rate was 93, her respiratory rate was 16, and her oxygen
saturation was 100% on 5 liters via nasal cannula. In
general, the patient appeared older than her stated age. The
patient was comfortable and in no acute distress; fatigued.
Head, eyes, ears, nose, and throat examination revealed the
mucous membranes were very dry. The patient had cracked
lips. The oropharynx was clear. Pupils were equal, round,
and reactive to light. No exudates. No bleeding. The
conjunctivae were pink. The neck was supple. No
thyromegaly. Jugular venous pulsation was flat. Chest
examination revealed breath sounds throughout without wheezes
or crackles. Cardiovascular examination revealed a regular
rate and rhythm; tachycardic. No murmurs were appreciated.
Skin examination revealed no rashes. The skin was severely
dry with tinting with scaling. The abdomen revealed a large
vertical well-healed scar. Very prominent xiphoid. Could
palpate the bowel, but no tenderness. No hepatosplenomegaly.
No guarding or rebound. Extremity examination revealed the
extremities were thin. No splinter hemorrhages. No lesions.
No edema. No clubbing or cyanosis. The extremities were
cool. Strength was [**3-25**] to [**4-25**] throughout. Neurologic
examination revealed no focal deficits. The patient was
alert and oriented times three. The patient followed
commands and answered questions appropriately but slowly.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed the patient's white blood cell count
was 19.9, her hematocrit was 42.6, and her platelets were
252. Her sodium was 142, potassium was 3.5, chloride was
104, bicarbonate was 33, blood urea nitrogen was 9,
creatinine was 0.6, and her blood glucose was 99. Her
calcium was 7, her magnesium was 1.5, and her phosphate was
3.8. Her alanine-aminotransferase was 36, her aspartate
aminotransferase was 51, her alkaline phosphatase was 105,
her amylase was 27, her total bilirubin was 0.6, and her
lipase was 9. Creatine kinase was 16. Troponin was less
than 0.01. Urinalysis showed no nitrites, 21 to 50 red blood
cells, and 6 to 10 white blood cells. Arterial blood gas was
7.3/60/189. Lactate went from 3 to 1.8 to 1. Blood cultures
were no growth to date.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
abdomen showed a right lower lobe opacity, possible
aspiration pneumonia, a 2-mm nodule in the left upper lobe, a
right thyroid with low attenuation, loops of small bowel in
the upper abdomen without free air, severe kidney cysts
bilaterally, right hydronephrosis, and hydroureter. No
change from prior study, anasarca.
A chest x-ray showed bile in the left upper quadrant pushing
up the diaphragm.
Electrocardiogram was read as sinus tachycardia.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient is a 48-year-old female with multiple medical
problems who presented to the Emergency Department with a
picture of sepsis. The sepsis protocol was initiated. She
received a great deal of intravenous fluids. She was started
on antibiotics of vancomycin, aztreonam, and Flagyl. She
actually responded quite well to these treatments and did not
require intubation nor did she go into organ/system failure.
None of her blood cultures grew an organism out. She did
have one positive urine culture for Streptococcus bovis;
raising the question of endocarditis, but she had no other
signs, or symptoms, or positive laboratory values pointing in
this direction.
The patient spent five in the Medical Intensive Care Unit
before being transferred to a floor bed.
1. FEVER AND INCREASED WHITE BLOOD CELL COUNT ISSUES: With
negative blood cultures and what appeared to be a pneumonia
on chest x-ray, in the end this was felt due to a pneumonia.
The patient responded quite well to the over 10 liters of
fluid and antibiotics which she received. At the time of
discharge, she had received seven days of vancomycin,
aztreonam, and also a shorter course of Flagyl which had been
stopped. Her white blood cell count had responded nicely.
She had been afebrile for several days. No blood cultures
grew out any organisms. As noted, she did have a urine
culture which grew out Streptococcus bovis; the significance
of which was not entirely clear.
She also did receive one dose of stress-dose steroids which
seemed to improve her course greatly during her time in the
Medical Intensive Care Unit.
A random cortisol was checked and was within normal limits;
although, this was hard to interpret with the patient on
prednisone. A thyroid-stimulating hormone was checked and
found to be quite low, but the T4 was normal. The patient's
levothyroxine was stopped for several days, and then she was
restarted at a lower dose of 75 mcg by mouth every day.
On [**2111-12-16**], the patient was to receive a midline
intravenous line for administration of intravenous
antibiotics once she returned to her extended care facility.
It was also worth noting that the presence of positive
Streptococcus bovis culture was concerning for translocation
of this organism from the gut; in particular, in the presence
of colon cancer. I do not believe the patient has had a
screening colonoscopy, and this is strongly recommended, and
this was discussed with her gastroenterology physician.
2. SHORTNESS OF BREATH ISSUES: The patient responded well
to fluid resuscitation and quickly appeared comfortable on 3
liters nasal cannula in the Medical Intensive Care Unit. An
arterial blood gas did show respiratory acidosis, her lactate
quickly trended down. She did have several episodes of
tachycardia where she was short of breath which was felt
likely secondary to pain and anxiety.
Prior to discharge, the patient was saturating 100% on 2
liters via nasal cannula; although, she did express some
feelings of shortness of breath. She was offered an
albuterol inhaler as needed to treat this shortness of
breath.
3. SYSTEMIC LUPUS ERYTHEMATOSUS AND POSITIVE ANTICARDIOLIPIN
ANTIBODY ISSUES: The patient is known to hypercoagulable,
having had a pulmonary embolism while on anticoagulation. On
the prior admission, an inferior vena cava filter was placed.
On this admission, the patient was continued on her Coumadin;
however, likely its interaction with antibiotics caused her
to be supratherapeutic. Therefore, her Coumadin was held for
several days, but likely to be restarted upon her discharge
at a slightly lower dose.
4. NUTRITIONAL AND DYSPHAGIA ISSUES: The patient was
followed by the Gastroenterology team while in the hospital.
It was clear that the patient was nutritionally deficient at
this point, and consideration was made for placing a
percutaneous endoscopic gastrostomy tube to aid in nutrition.
However, it was decided that the patient would try aggressive
oral feedings; possibly with a liquid diet for the next
several weeks and then would follow up with her
gastroenterologist (Dr. [**Last Name (STitle) 22318**] here at [**Hospital1 190**]. At that time, the decision will be made
whether to place the percutaneous endoscopic gastrostomy
tube. In the meantime, the patient will also continue on
Reglan and Protonix as well as calcium carbonate, folic acid,
and lactulose and Colace as needed for bowel movements.
The patient had a small-bowel follow-through x-ray study
performed during this admission. The results of this test
were not known at the time of this dictation.
5. HYPOTHYROIDISM ISSUES: As noted, the patient's
thyroid-stimulating hormone was suppressed on admission with
a normal T4. Her levothyroxine was initially held and then
restarted at a decreased dose of 75 mcg by mouth once per
day.
6. HEADACHE ISSUES: Headaches are a chronic problem for
this patient; thought to be migraines. The patient has been
resistant to a trial of Imitrex. The patient was continued
on Midrin as well as the pain medications; the MS Contin and
morphine sulfate immediate release. It was recommended that
the patient attempt to optimize these treatments as an
outpatient with consultation with a neurologist.
7. CHRONIC PAIN/PERIPHERAL NEUROPATHY ISSUES: The patient
was maintained on her home regimen of MS Contin and morphine
sulfate immediate release tablets as needed.
8. ANEMIA ISSUES: The patient has anemia of chronic disease
by iron studies and had a stable hematocrit during her stay.
No guaiac-positive stool were noted. Daily complete blood
counts were checked.
9. PSYCHIATRIC ISSUES: The patient was continued on
buspirone 15 mg by mouth three times per day as well as on
lorazepam 0.5 mg by mouth three times per day. The patient
was also continued on her mirtazapine 30 mg by mouth at
bedtime.
DISCHARGE DISPOSITION: The patient was to be discharged to
an extended care facility.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to contact her primary care
doctor with any chest pain, shortness of breath, increased
nausea or vomiting, severe diarrhea, fevers, chills, or
dizziness.
2. The patient was instructed to follow up with her primary
care doctor within one to two weeks.
3. The patient was instructed to follow up with Dr. [**Last Name (STitle) 22318**]
on [**2112-1-5**] at 1 p.m.
4. The patient was instructed to have her INR checked on
[**2111-12-21**]; and her Coumadin dose adjusted accordingly.
5. The patient was instructed to try to increase her
nutritional intake as much as possible.
6. The patient was instructed that she had a magnetic
resonance imaging appointment on [**2111-12-21**] at 8:45
a.m.
7. The patient was instructed that she had a Neurology
appointment on [**2111-12-29**] at 6 p.m.
MEDICATIONS ON DISCHARGE: (Medications on discharge were as
follows)
1. Multivitamin one tablet by mouth once per day/
2. Protonix 40 mg by mouth once per day.
3. Mirtazapine 30 mg by mouth once per day.
4. Lactulose 15 mL to 30 mL by mouth at hour of sleep as
needed.
5. Colace 100 mg by mouth twice per day.
6. Calcium carbonate 500 mg by mouth three times per day
(with meals).
7. Albuterol inhaler 1 to 2 puffs inhaled as needed q.6h.
9. Vitamin D 400 International Units by mouth every day.
10. Folic acid 1 mg by mouth once per day.
11. Lorazepam 0.5 mg by mouth twice per day.
12. Reglan 10 mg by mouth four times per day (before meals
and at bedtime).
13. Buspirone 15 mg by mouth three times per day.
14. Midrin one to two tablets by mouth q.8h. as needed (for
migraines).
15. Prednisone 7.5 mg by mouth once per day.
16. Morphine sulfate 15 mg q.4-6h. as needed (for
breakthrough pain).
17. Morphine sulfate immediate release 30 mg q.12h.
18. Levothyroxine 75 mcg by mouth every day.
19. Cyanocobalamin 1000 mcg once per day.
20. Vancomycin 1000 mg intravenously q.12h. (for seven
days).
21. Aztreonam [**2108**] mg intravenously q.12h. (for seven days).
22. Coumadin 2 mg by mouth at bedtime (adjust this dose
based on monitoring of INR levels). The patient should have
her INR checked on [**2111-12-21**].
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Anemia.
3. Malnutrition.
4. Dysphagia.
5. Systemic lupus erythematosus.
6. Pulmonary embolism/infarction.
CONDITION AT DISCHARGE: Condition on discharge was good but
malnourished.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2111-12-16**] 14:56
T: [**2111-12-16**] 16:36
JOB#: [**Job Number 33533**]
Admission Date: [**2111-12-18**] Discharge Date: [**2111-12-24**]
Date of Birth: Sex:
Service:
ADDENDUM: This addendum covers the states [**2111-12-18**] to
[**2111-12-24**] and revises the discharge medications and
instructions.
CONTINUATION OF HOSPITAL COURSE:
Th patient continued to do well on her antibiotic regimen and
completed a ten day course of Vancomycin, Aztreonam with no
return of fevers or elevated white blood cell count. The
patient's pain was well controlled with MS-Contin, Midrin,
Tylenol and Nortriptyline added at night. The patient was
transitioned off of Coumadin and onto Lovenox while she
underwent an upper endoscopy procedure. The patient will go
out on Lovenox and then will need to be reloaded with
Coumadin and made therapeutic on Coumadin for her positive
anticardiolipin antibody syndrome and history of pulmonary
embolus.
An upper endoscopy was performed which was remarkable for
food contents noted in the lower third of the esophagus,
above the gastroesophageal junction. The contents were
cleared and the dilation was performed. The patient also
underwent MRCP to follow-up on CT findings which showed
dilated common bile duct. The MRCP and the CT findings were
essentially identical to similar tests done three years ago
at [**Hospital6 1129**]. The MRCP was noted for
dilatation of the intra and extra hepatic ducts without
masses or stones; greater dilatation on the left sided
hepatic ducts with hepatic atrophy. This finding will be
followed up as an outpatient with her gastroenterologist.
The patient will also likely need a colonoscopy with her
gastroenterologist, Dr. [**Last Name (STitle) 12590**].
The patient also had a nasogastric tube placed under
fluoroscopic for tube feedings and tube feedings were begun
and advanced towards the goal rate of 50 cc per hour of
Pro-Balance. The patient tolerated these tube feedings
without vomiting or diarrhea.
Rheumatology saw the patient regarding her diagnosis of
systemic lupus erythematosus. The patient will be instructed
to follow-up with the rheumatology service as an outpatient
for further evaluation of this condition. The patient was
also seen by the surgery consult service with regards to the
surgical placement of a jejunostomy feeding tube. They felt
that she would benefit from aggressive nutritional repletion
first, before undergoing any surgery for fear that she would
not heal well from surgery at this time. The patient will be
discharged to a rehabilitation facility for further NJ tube
feedings and p.o. feedings as tolerated. She will continue
to follow-up with her specialty physicians while there.
REVISED DISCHARGE MEDICATIONS:
VG capsule once a day.
Protonic 40 mg once a day.
Mirtazapine 30 mg once a day.
Lactulose 15 ml once at bedtime.
Colace twice a day 100 mg.
Calcium carbonate 500 mg three times a day with meals.
Albuterol inhaler.
Vitamin D3 400 unit tablet once a day.
Folic acid 1 mg once a day.
Ativan two times a day.
Reglan one tablet four times a day.
Buspirone 15 mg three times a day.
Midrin capsule one to two tabs every eight hours as needed
for migraine.
Prednisone 7.5 mg once a day.
Morphine sulfate 15 mg tablet every four to six hours for
break through pain.
Morphine sulfate 30 mg SR tablet every 12 hours.
Levothyroxine 35 mcg once a day.
Coumadin 2 tablets once a day; please adjust this dose based
on monitoring of INR.
Lovenox 50 mg subcutaneous every 12 hours. This medication
can be stopped once the INR is in therapeutic range.
Miconazole nitrate powder three times a day as needed.
Nortriptyline 10 mg once at bedtime.
Tylenol 650 mg every six hours.
Zofran 2 mg intravenous as needed.
Vitamin B-12 1000 mg injection once a month.
FOLLOW-UP APPOINTMENTS:
The patient is to follow-up with Dr. [**Last Name (STitle) 12544**] in neurology on
[**2111-12-29**].
To follow-up with Dr. [**Last Name (STitle) 12590**] in gastroenterology on [**2112-1-5**].
The patient will have a rheumatology appointment made for
follow-up for her Systemic lupus erythematosus.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Last Name (NamePattern1) 33534**]
D: [**2111-12-24**] 10:55
T: [**2111-12-24**] 10:58
JOB#: [**Job Number 33535**]
Admission Date: [**2111-12-11**] Discharge Date: [**2111-12-29**]
Date of Birth: [**2063-4-17**] Sex: F
Service: [**Hospital1 **]
ADDENDUM COVERING HOSPITAL COURSE FROM [**Date range (3) 33536**]:
1) GI/NUTRITION: The patient continued to tolerate her tube
feeds well during this time. Her nasojejunal feeding tube
came out during this time period, likely in a moment of
disorientation on the patient's part. It was easily replaced
without incident, and feedings were restarted at that time.
It will be important to make sure that the tube is
well-secured during the period that the patient requires
these feedings. She continued to have her chronic nausea and
occasional vomiting, as well. This was essentially unchanged
from baseline and was able to be treated with antiemetic
medication, such as compazine. The patient should be
encouraged to take ad lib POs, in addition to her tube feeds.
A soft low-residue diet was recommended, along with Boost
supplementation as tolerated. The patient will follow-up
with Dr. [**First Name4 (NamePattern1) 12589**] [**Last Name (NamePattern1) 22318**] on [**2112-1-5**] for gastroenterology
follow-up.
2) PAIN CONTROL: The patient has chronic neuropathic pain
which continued to be well-controlled with the addition of
nortriptyline 10 mg hs. In addition, the patient remained on
MS-Contin and morphine po for breakthrough, along with Midrin
for her chronic headaches. One might consider, over the
long-term, trying to wean the patient off of the opiate
regimen, as this may be contributing to her chronic nausea.
3) PULMONARY: The patient had one episode of desaturation on
[**2111-12-26**]. The cause of this was unclear, maybe possible
fluid overload. However, a chest x-ray did not show any
evidence of infiltrate or CHF. Nonetheless, the patient
initially responded well with her oxygenation returning to
normal. She was started on low-dose lasix, and she continued
to have a decreasing oxygen requirement over the remainder of
her stay and had no complaints of respiratory distress
whatsoever. We believe this to be an isolated incident, not
something which requires chronic monitoring. In addition,
she was pancultured. Urine cultures and blood cultures were
sent, and they did not reveal any sources of infection, and
she remained afebrile during the rest of her stay and did not
require any further antibiotic treatment. In addition, at
that time she had a CTA which was negative for any new PEs.
It did show improvement of her known old PE from
approximately 1 month ago. The patient remains
anticoagulated with Lovenox, as well as continues to have an
IVC filter in place for prevention of further pulmonary
emboli.
4) SYSTEMIC LUPUS ERYTHEMATOSUS/ANTICARDIOLIPIN ANTIBODY
POSITIVE: As noted above, the patient is anticoagulated with
Lovenox and has an IVC filter in place. She had been off of
her Coumadin for possible J-tube placement, but surgical
opinion was that she needed to have much improved nutrition
before any surgery was to be performed. So, her Coumadin was
restarted on the day of discharge and once therapeutic, she
can be removed from the Lovenox. She will require monitoring
of her INR to determine when her Coumadin will be at a
therapeutic level. She continued on prednisone for her
previously diagnosed systemic lupus erythematosus, and she
will have a follow-up appointment with rheumatology on
[**2111-12-31**] with Dr. [**First Name (STitle) **] [**Name (STitle) 3748**] in the [**Hospital Ward Name **] Bldg, 5th Fl., at
[**Hospital1 18**]. The patient also has a hematology appointment with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] on [**2112-1-22**] at 10:00 am.
5) ANEMIA: The patient does have a chronic anemia, and she
is being treated with folate with B12 injections with
thiamine, as well. The source is not entirely clear.
However, her hematocrit has remained essentially stable over
the past 5 days. It should be checked in 3 days to confirm
that there has been no further drop in hematocrit from her
baseline of 26-30.
6) HYPOTHYROID: The patient is on levothyroxine 75 mcg qd.
This was adjusted several weeks ago when her TSH had been
suppressed. A repeat TSH was within normal limits. It
probably bears rechecking in several weeks and adjusting the
dose of the levothyroxine as necessary.
7) PSYCH: The patient is maintained on a number of
psychotropic medications including mirtazapine, buspirone and
nortriptyline. These medications were essentially stable
throughout her stay, with the exception of the nortriptyline
which was added to ease her neuropathic pain, and this should
be continued.
DISCHARGE DISPOSITION: To extended care facility.
DISCHARGE INSTRUCTIONS:
1. Contact your primary doctor with any chest pain, shortness
of breath, increased nausea or vomiting, severe diarrhea,
fever, chills or dizziness.
2. You should see your primary doctor within 1-2 weeks, that
is Dr. [**Last Name (STitle) **] [**Name (STitle) 32412**], ([**Telephone/Fax (1) 9482**].
3. You are to see Dr. [**Last Name (STitle) 22318**] [**2112-1-5**] at 1:00 pm.
4. You are to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12544**] in neurology; the
appointment date was noted on the discharge paperwork, phone
# ([**Telephone/Fax (1) 15319**].
5. You are to see Dr. [**First Name (STitle) **] [**Name (STitle) 3748**] in rheumatology on [**2111-12-31**]
at 9:30 am, ([**Telephone/Fax (1) 1668**].
6. You are to see [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**], hematology, [**2112-1-22**] at 10:00
am.
DISCHARGE MEDICATIONS:
1. Vege capsule 1 cap qd.
2. Protonix 40 mg qd.
3. Mirtazapine 30 mg at bedtime.
4. Lactulose 15 ml at bedtime.
5. Colace 100 mg [**Hospital1 **].
6. Calcium carbonate 500 mg tid with meals.
7. Albuterol inhaler 1-2 puffs q 6 h prn.
8. Vitamin D 400 U qd.
9. Folic Acid 1 mg qd.
10.Ativan 0.5 mg tid.
11.Buspirone 15 mg tid.
12.Midrin 1-2 tabs q 8 h prn migraine.
13.Prednisone 7.5 mg qd.
14.Morphine sulfate 15 mg tablet q 4-6 h for breakthrough
pain.
15.Morphine sulfate 30 mg SR tablet q 12 h.
16.Levothyroxine 75 mcg qd.
17.Coumadin 2 mg q hs--please adjust this dose based on
monitoring of INR.
18.Lovenox 50 mg q 12 h--you can stop this medication once
the INR is in therapeutic range.
19.Miconazole powder tid prn.
20.Nortriptyline 10 mg at bedtime.
21.Tylenol 2 tablets q 6 h prn pain.
22.Vitamin B12, 1 mg injection q month.
23.Thiamine 100 mg qd.
24.Lasix 20 mg qd for 5 days.
25.Compazine 5 mg 1-2 tablets q 6 h prn nausea.
DISCHARGE DIAGNOSES:
1. Systemic lupus erythematosus.
2. Dysphagia.
3. Malnutrition.
4. Anemia.
5. Pneumonia.
6. History of pulmonary embolism.
DISCHARGE CONDITION: Good and stable, but malnourished.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2111-12-30**] 11:18
T: [**2111-12-30**] 11:19
JOB#: [**Job Number 33537**]
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31,312
| 127,718
|
47659
|
Discharge summary
|
report
|
Admission Date: [**2168-7-25**] Discharge Date: [**2168-8-8**]
Date of Birth: [**2109-11-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Alcohol intoxication
Major Surgical or Invasive Procedure:
brain biopsy
History of Present Illness:
Reason for MICU admission: Alcohol intoxication, tachycardia,
and need for monitoring of respiratory status.
This is a 58 y.o. male with history of CAD, SVT, and alcohol
abuse requiring several ICU stays for withdrawal who was brought
in today by ambulance after being found by neighbor in hallway
of apartment complex. He drinks 1 pint of had liquor daily, and
had drank [**1-2**] pints of vodka by 1PM prior to being found by his
neighbor. [**Name (NI) **] denies loss-of-consciousness, fall, or head trauma
but does not clearly recall all the events that led up to the
arrival at [**Hospital1 **].
.
In the ED, patient was given banana bag, potassium, lorazepam
1mg IV x 2, and diazepam 5mg IV x 1. He was noted to be
tachycardic to 160s, which was felt to be more due to his SVT
rather than withdrawal. Given this degree of tachycardia and
potential need for respiratory monitoring with benzodiazepine
requirement, patient was admitted to MICU.
Review of systems: He denies any headache, dizziness, nausea,
vomitting, visual disturbance, chest pain, shortness of breath,
diarrhea, melena, BRBPR, fevers, chills, tremulousness,
hallucinations, or rashes. He denies any lower extremity
swelling although he does report right heel pain.
Past Medical History:
HTN
CAD s/p RCA stent in [**8-/2164**]
s/p closed fract tib/fib
SVT (AVRT v. AVNRT)
Chronic EtOH abuse (no h/o seizures; s/p detox 3 years ago,
referred to [**Hospital1 1680**] house partial hospitalization program [**5-5**])
Depression/anxiety ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 66064**] [**Numeric Identifier 100681**] @ [**Hospital1 1680**] JP; [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 12528**] [**Telephone/Fax (1) 5260**])
Social History:
Unemployed, living alone in [**Location (un) **] MA. Graduated from [**University/College 72402**]with a major in business, most recent work was as a
security guard. Originally from [**Hospital1 40198**] MA. No siblings or other
family. +EtOH abuse. Remote tobacco use. Denies illicit drugs.
Family History:
Mother with depression and CAD.
Physical Exam:
Physical Exam:
Vitals:96.6, 158/109, 160=>100 with carotid sinus massage, 18,
99% on 2 litres nasal cannula
GEN: Disheveled male, NAD
HEENT: EOMI, PERRL 4mm=>2mm, dry mucous membranes, sclera
anicteric, poor dentition
NECK: Obese, no JVD, no lymphadenopathy, trachea midline
COR: Tachycardic, regular rhythm, no M/G/R, normal S1 S2, radial
and DP pulses intact
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS
EXT: No C/C/E
NEURO: A&O x 3, CN II-XII intact, DTR +1 patellar, moves all 4
extremities
SKIN: Several subcentimeter flesh-colored nodules on right
wrist/forearm, no jaundice, ecchymoses, or other dermatitis
Pertinent Results:
ECG: Sinus tachycardia, narrow complex, no ST-T changes,
suggestive of LVH but does not meet criteria.
[**2168-7-24**] 07:30PM WBC-5.8 RBC-4.32* HGB-13.2* HCT-38.3* MCV-89
MCH-30.5 MCHC-34.4 RDW-15.4
[**2168-7-24**] 07:30PM PLT COUNT-231
[**2168-7-24**] 07:30PM NEUTS-76.8* LYMPHS-17.2* MONOS-4.4 EOS-1.3
BASOS-0.4
[**2168-7-24**] 07:30PM GLUCOSE-176* UREA N-11 CREAT-0.8 SODIUM-144
POTASSIUM-2.9* CHLORIDE-103 TOTAL CO2-23 ANION GAP-21*
[**2168-7-24**] 07:30PM ETHANOL-319*
[**2168-7-25**] 03:20AM K+-3.6
Chest x-ray notable for bibasilar atelectasis and elevated right
hemidiaphragm unchanged from prior.
.
Ct head:1. No evidence of hemorrhage or mass effect.
2. Similar appearance of 2-cm hypodense lesion in the right
parietal lobe. Differential diagnosis is broad and includes
infectious etiologies assessed as cysticercosis, metastasis, and
occult vascular malformation. MRI with contrast would be useful
for further characterization of this finding.Findings discussed
with Dr. [**Last Name (STitle) 60928**] by telephone at the time of interpretation.
.
MRI head-Findings consistent with the presence of two
intracranial mass lesions, one redemonstrated compared with the
prior CT scan, but the other lesion, involving the glomus of the
choroid plexus on the left side, more clearly differentiated on
the present study. If, indeed, the patient has neurofibromatosis
1, astrocytoma could be considered as a cause of these lesions,
although the presence of apparent blood products in the
right-sided lesion would be atypical for such a diagnosis.
.
MRI C/T/L spineFINDINGS: Within the cervical region, there is no
spinal cord compression seen. The fat-saturated images show no
sign of pathological contrast enhancement either within the
cord, or within the limitations of the artifact- degraded
parasagittal scans, within the paraspinal regions, either.No
definite area of spinal cord compression is seen within the
thoracic region nor are there visible areas of pathological
enhancement. Similarly, within the lumbar spine, there is no
definite sign for a mass lesion within the spinal canal causing
cauda equina compression. However, overlying the distal sacrum
is a mildly enhancing 13 by 28 by 34mm soft tissue mass,
superficially located, that perhaps corresponds to a
neurofibroma correlating with the stated history of
neurofibromatosis-1. However, in that regard, there is no
evidence for dural ectasia, a finding frequently noted in this
disorder. There are no evident schwannomas involving the neural
foramina.
There is a moderately prominent right-sided L5-S1 disc
herniation effacing the ventral thecal sac margin along its
right side, as well as totally effacing the right S1 nerve root
sleeve within its lateral recess.
CONCLUSION: No definite CNS schwannomas. See above report for
additional findings.
.
Brief Hospital Course:
Assesment:58 y.o. male with history of EtOH abuse, SVT, CAD who
presents for management of EtOH withdrawal.
# EtOH withdrawal -
Pt received Diazepam 5mg PO q4H PRN CIWA > 8 in addition to
Thiamine, Folate, and MVI daily. A CXR was done to r/o
aspiration. A CT Head was done to r/o a subdural bleed. Pt
found to have hypodense lesions concerning for
Neurofibromatosis. Neurology, Dermatology, and Neurosurgery were
consulted and followed the patient. Neurosurgery biopsied the
lesion and patient will follow up results as an outpatient.
# Tachycardia - alcohol withdrawal vs. SVT. Pt well controlled
on Metoprolol but Pt had an episode of tachycardia to 140s found
to be MAT on EKG, treated with 2.5mg Metoprolol with good
response while in the MICU. After transfer to the floor, and an
additional episode of SVT/MAT, pt's metoprolol doses was
increased to 75mg TID. Pt's blood pressure and heart rate have
been well controlled on current dose. He will be dc/d on Toprol
as he often is non-compliant with medications.
.
# CT Lesion- Found on Head CT done [**2168-7-25**] showing 2cm
hypodense lesion in right parietal lobe. A neuro and derm
consults were called and pt was given a clinical diagnosis of
neurofibromatosis (neurofibromas, axillary freckling, cafe [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 28584**] spots). Pt had an MRI of his brain and spine. Pt underwent
brain bx to help in diagnosis of the lesion. Pt needs to get an
outpatient serum neurofibromatosis mutation checked to confirm
the diagnoisis. Pt will follow up with neurology and
neurosurgery as an outpatient.
.
#depression/anxiety/ETOH abuse-psychiatry and social work were
consulted. Psychiatry evaluated patient in terms of his capacity
to refuse inpatient substance abuse care. He was continued on
his outpatient depression/anxiety regimen. Social work actively
participated in helping patient to maintain his [**Last Name (un) **] residence
and to provide him with outpatient, partial rehabilitation
resources as well as community resources. Pt will be following
up with his outpatient social worker, psychiatrist, and PCP
after discharge.
.
#dizziness: Pt complained of generalized weakness and dizziness
after the brain biopsy. Neurosurgery evaluated the patient and
did not find any acute findings. Pt was encouraged to maintain
good po and fluid intake. Physical therapy evaluated the patient
and found no acute physical therapy needs. Pt reported that his
dizziness/weakness have resolved.
Medications on Admission:
Per [**5-/2168**] Discharge Summary:
1. Aspirin 81 mg Tablet
2. Atorvastatin 10 mg
3. Citalopram 20 mg
4. Folic Acid 1 mg
5. Lisinopril 5 mg
6. Metoprolol Tartrate 50 PO BID
7. Hexavitamin
8. Quetiapine 25 mg PO BID
9. Thiamine HCl 100 mg
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
12. Dexamethasone 2 mg Tablet Sig: see directions Tablet PO see
instructions for 5 days: Please take 4mg (2pills) [**Hospital1 **] on 1st
day. Then take 2mg (1pill) TID next day. Then, 2mg (one pill)
[**Hospital1 **] 3rd day. Then 2mg (one pill) daily for 1 day. Then 1 mg
(half pill) daily for 1day.
Disp:*11 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Major:
alcohol withdrawal
SVT
newly diagnosed brain mass
neurofibromatosis, new diagnosis
hypertension
depression
Discharge Condition:
good
Discharge Instructions:
You were admitted for alcohol intoxication and withdrawal. You
were also found to have a condition called neurofibromatosis and
a new mass in your brain that was biopsied. Your blood pressure
medications were changed for better control of your hypertension
and heart rate. It is important that you follow up with your
outpatient psychiatrist, social worker, and AA meetings and
neurosurgeon. If you develop fevers, chills, confusion,
weakness, numbness/tingling please contact your doctor or go to
the emergency room. Please take your medications as directed
below and follow up with the necessary appointments.
Also, we have started you on Toprol xL because you have had some
fast heart rhythms. Other than that, you should stay on the same
medications. Please stop drinking, this is really important for
your life and health.
Followup Instructions:
Please call [**Telephone/Fax (1) 250**] to schedule an appt to see your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] [**Name (STitle) **]
.
Neurology: Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2168-8-25**] 9:00
.
Please call the neurosurgery clinic (Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 18865**] schedule follow up after the biopsy in [**9-11**] days. The
office will be contacting you at home to schedule this follow
up. They are aware that you need to be seen in 10-14days.
.
Please call your psychotherapist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12528**] at
[**Telephone/Fax (1) 5260**].
.
Please follow up with your outpatient alcohol rehabilitation
program. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18741**] of social work is providing you with
this information as well as information for community resources.
[**Telephone/Fax (1) 100684**]
.
Adult dual dx partial hospitalization program
at [**Hospital1 1680**]/HRI in [**Location (un) **] at [**Street Address(2) 100685**]. [**Location (un) **]
([**Telephone/Fax (1) 35932**]). Will start (wed [**8-10**])after discharge.
|
[
"237.70",
"291.81",
"V45.82",
"300.4",
"414.01",
"427.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.13"
] |
icd9pcs
|
[
[
[]
]
] |
10079, 10085
|
6001, 8494
|
335, 349
|
10243, 10250
|
3136, 3759
|
11130, 12397
|
2449, 2482
|
8784, 10056
|
10106, 10222
|
8520, 8761
|
10274, 11107
|
2512, 3117
|
1351, 1623
|
275, 297
|
377, 1332
|
3767, 5978
|
1645, 2123
|
2139, 2433
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,868
| 191,429
|
52922
|
Discharge summary
|
report
|
Admission Date: [**2164-1-22**] Discharge Date: [**2164-1-25**]
Date of Birth: [**2090-1-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
73F h/o DM, PVD s/p bilateral BKA, ESRD and diastolic CHF with
multiple admissions for acute pulmonary edema (most recent
[**2164-1-8**]) presents with acute SOB at home today. She reports
that at her last HD, Friday [**2164-1-20**] she didn't have
enough fluid taken off and she had progressive DOE throughout
the day warranting a call to EMS. EMS arrived and gave her
Lasix and CPAP. She was brought to the ED where her CXR
revealed pulmonary edema. She remained on CPAP and was started
on a nitro gtt peripherally after failed attempts at femoral
line cannulation for CVL placement.
.
She denies CP, nausea, or diaphoresis. Noted to be in
respiratory distress on EMS arrival and placed on CPAP with sats
mid-90s.
Past Medical History:
# CKD V on hemodialysis; qMWF schedule at [**Location (un) **] [**Location (un) **]
# DM2 on insulin
# HTN
# Chronic diastolic CHF (LVEF >75%) with a history of
tachycardia-induced acute LVOT obstruction
# Hyperlipidemia
# PVD s/p bilateral BKAs (left in [**2156**]; right in [**2157**])
# Paroxysmal a-flutter s/p failed ablation with subsequent
atrial fibrillation; on warfarin
# Chronic nighttime hypoxemia on 3 L/min nc
# Secondary hyperparathyroidism
# No occlusive coronary disease on cardiac cath [**12/2162**]
# Left eye blindness
# Mild functional mitral stenosis
# GERD
# Tobacco abuse-- still smokes [**12-23**] PPD as of [**12-30**]
# h/o VRE UTI's
# H/o Tibial fracture
Social History:
The patient denies alcohol and IV drug use. She states that she
smokes approximately 3 cigarettes daily and has history of ~30
pack-year. She lives in a senior citizen center; her daughter
lives with her.
Family History:
Her father died in his 90s of complications of DM2 and mother at
the age of 102 of a stroke. Patient had a sister who died in her
70s of cancer (unknown type and site) and 2 brothers that died
stroke and brain cancer. She has 7 children who are healthy. Her
family history is significant for coronary artery disease,
cancer, and diabetes.
Brief Hospital Course:
# SOB: Acute on chronic, likely due to acute pulmonary edema
from volume overload and diastolic CHF in the setting of
hypertensive urgency and tachycardia with function mitral
stenosis. BNP [**Numeric Identifier 109109**]. IN the MICU pt was weaned off of BiPAP
and nitro gtt, restarted on home BP meds. On [**1-23**] had 1.7L taken
off at HD and was neg 4L before going to floor. Pt with
adequate O2 sats on room air after HD on the floor and was
discharged with O2 sats around 99% on RA. She will continue on
inhalers for symptoms control at home. In order to control the
tachycardia that may have been playing a role in worsening her
diastolic CHF and symptoms she was switched to 80mg of verapamil
Q6H. To prevent hypotension her toprol was also decreased to 100
from 150mg. She was also set up to get HD an extra hour on the
weekend to prevent fluid overload on the weekends. In addition
she will take isosorbide mononitrate on Sundays to help with her
symptom control.
# Positive U/A: h/o Klebsiella UTI sensitive to CTX so was
started on CTX, received 2 doses, and then was discharged on
cefpodoxime PO. Her PCP will attempt to obtain another urine
sample to insure clearance after her 7 day course of abx.
# ESRD: Emergent HD on [**1-23**] with 1.7L fluid taken off improved
SOB. She was then continued on M/W/F HD and will have an extra
hour of HD on the weekend as above.
# PAF: Had brief episode of atrial flutter at HD with transient
hypotension to 80s, quickly returned to 120s and returned to
sinus after HD. Coumadin, beta-blocker, and amiodarone were
continued.
# DM2: Home insulin 4 NPH [**Hospital1 **] with Humalog sliding scale.
# Sub-therapeutic INR: She was restarted on coumadin at home
dosing and will be followed up by [**Hospital 191**] [**Hospital 2786**] clinic to
ensure she gets back to goal INR [**1-24**] for her afib. It was felt
that she was low enough risk to not need a heparin bridge. Given
that she will be taking antibiotics it was felt that she should
not have a bolus of coumadin and instead was continued on just
her normal dose of coumadin.
Medications on Admission:
Medications on Admission: *per [**2164-1-5**] d/c summary*
1. Valsartan 160 mg Tablet qd
2. Lisinopril 10 mg qd
3. Metoprolol Succinate 150 mg daily
4. Simvastatin 40 mg qd
5. Amiodarone 200 mg qd
6. Warfarin 2 mg Tablet(MO,WE,FR).
7. Warfarin 1 mg ([**Doctor First Name **],TU,TH,SA).
8. Pantoprazole 40 mg Tablet daily
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puffs q4h prn
10. Brimonidine 0.15 % Drops 1 Drop Ophthalmic [**Hospital1 **]
11. Dorzolamide-Timolol 2-0.5 % Drops Sig: (1) Drop [**Hospital1 **]
12. Folic Acid 1 mg qd
13. Latanoprost 0.005 % Drops(1) Drop Ophthalmic HS
14. Sevelamer Carbonate 800 mg PO TID
15. Calcium Acetate 667 mg PO TID
16. Aspirin 81 mg qd
17. Insulin NPH 4 U twice a day with a humalog sliding scale
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*2*
3. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO QSU,TU,TH,SA ().
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
12. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four
(4) units Subcutaneous twice a day.
15. Humalog 100 unit/mL Solution Sig: as directed per sliding
scale Subcutaneous four times a day.
16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
17. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
18. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*90 caps* Refills:*2*
20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
21. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO QSUNDAY ().
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
22. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
23. Valsartan 160 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] [**Location (un) 269**]
Discharge Diagnosis:
Pulmonary edema
ESRD
UTI
Discharge Condition:
The patient was afebrile, hemodynamically stable with HR in the
70s and without urinary symptoms prior to discharge.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
You were admitted to the hospital with fluid in your lungs. This
was probably caused by a fast heart rate. We have given you
hemodialysis to take the fluid out of your lungs. We have also
changed some of your medications to keep your heart rate lower.
Also, while you were in the hospital you had a urinary tract
infection that we are treating with antibiotics. You should
continue taking these antibiotics until you run out.
Medication Changes:
START: Cefpodoxime 100mg by mouth twice daily for 6 more days
CHANGE: Verapamil to 80mg by mouth every 8 hours
CHANGE: Toprol XL to 100my by mouth daily
Please come back to the emergency room or call your doctor if
you have light-headedness, dizziness, palpitations, chest pain,
shortness of breath, swelling of your legs, weight gain, or any
other concerning symptoms.
Followup Instructions:
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
([**Telephone/Fax (1) 1300**]. She will check your urine for infection and make
sure you are taking your new medications appropriately.
Please continue hemodialysis as scheduled by your nephrologists.
Completed by:[**2164-1-25**]
|
[
"427.32",
"V49.75",
"599.0",
"V58.61",
"252.02",
"272.4",
"585.6",
"428.0",
"V58.67",
"530.81",
"424.0",
"250.00",
"403.91",
"428.33",
"427.31",
"458.21",
"V45.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7636, 7713
|
2400, 4494
|
335, 341
|
7781, 7899
|
8890, 9231
|
2037, 2377
|
5296, 7613
|
7734, 7760
|
4546, 5273
|
7923, 8475
|
8495, 8867
|
276, 297
|
369, 1090
|
1112, 1796
|
1812, 2021
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,060
| 117,616
|
13961
|
Discharge summary
|
report
|
Admission Date: [**2107-3-29**] Discharge Date: [**2107-4-3**]
Date of Birth: [**2034-9-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Respiratory failure, blast crisis
Major Surgical or Invasive Procedure:
# Central line insertion
# Arterial line insertion
# Intubation
History of Present Illness:
72M h/o Non-Hodgkin's lymphoma, secondary AML (M4) (transfusion
dependent), transferred to [**Hospital1 18**] ED from [**Hospital1 1474**] after
developing hypotension, fever and respiratory distress after
transfusion.
.
After receiving a blood transfusion on the day of admission, pt
developed dyspnea (88% on 4L NC), chills and diaphoresis, with T
100.1, and creatinine 3.9 from 1.8 earlier in [**Month (only) 958**]. Pt was
transferred to the [**Hospital1 1474**] ED where he was found to be
tachycardic, febrile to T 103, increasingly dyspneic, and
vomiting. Pt underwent elective intubated, after which he was
transferred to the [**Hospital1 18**] ED. En route, patient became
hypotensive despite 1.5 L NS bolus, and phenylephrine was
started.
.
Prior to admission, pt had been recently treated for a sinus
infection with levofloxacin and amoxicillin/clavulanate.
.
[**Hospital1 18**] ED course:
# VS: T 101.8, HR 130, BP 78/40, ventilated, O2 sat 10O%.
# Meds: Vancomycin, ceftazidime, diphenhydramine 50 mg IV x1,
acetaminophen.
# Notable labs: WBC 73.2 (blasts 26%), Cr 3.9, Na 132., LDH
1001, uric acid 15.8.
Past Medical History:
# Non-Hodgkin's lymphoma ([**2097**]), s/p fludarabine x 6 ([**2102**]),
rituximab [**11-8**]
# Acute myelogenous leukemia (M4), diagnosed [**5-/2106**]
--[**10/2106**]: Splenic radiation (2500cGy)
--12/10-18/07: Decitabine x4 c/b persistent cytopenias
Social History:
# Personal: Lives in [**Location 1475**], [**State 350**], with wife
# Professional: Retired elementary school principal
# Tobacco: Past, quit [**2059**]
# Alcohol: Social
Family History:
# Mother, died: GI malignancy
# Father, died 60s: Alcohol-related complications
Physical Exam:
VS: T 100.1, P 121, BP 85/95, SaO2 99% on vent A/C 550/22/5/100%
General: Sedated, intubated, NAD
HEENT: NCAT, small pupils, slow reaction to light bilaterally
Neck: Left IJ. JVP not noted
Chest: B rhonchi anteriorly
Cardiac: RRR, S1S2, holosytolic murmur heard throughout
precordium, best at RUSB
Abdomen: Soft, NT/ND, BS+
Extremities: 1+ BLE edema
Skin: No rashes or lesions noted
Neurologic: Sedated
Pertinent Results:
# CHEST (PORTABLE AP) [**2107-3-29**] 8:20 PM
1. Standard position of the endotracheal and NG tube.
2. Diffuse increased interstitial marking consistent with the
mild interstital edema. The differential includes congestive
heart failure, fluid overload or transfusion-related lung
disease (TRALI).
.
# TTE Echocardiogram [**2107-3-30**] 11:40:43 AM
No evidence of endocarditis or abscess seen. Dilated,
hypokinetic right ventricle with pressure/volume overload. Mild
mitral regurgitation.
.
# CT C-SPINE W/O CONTRAST [**2107-4-1**] 12:20 AM
1. No acute pathology to explain the patient's upper extremity
neurologic findings. Please note, MRI is more sensitive for
evaluation of cord pathology.
2. Right apical ground-glass opacity is nonspecific and may
represent underlying infection or alveolar edema.
.
# CT C-SPINE W/O CONTRAST [**2107-4-1**] 12:20 AM
1. No acute pathology to explain the patient's upper extremity
neurologic findings. Please note, MRI is more sensitive for
evaluation of cord pathology.
2. Right apical ground-glass opacity is nonspecific and may
represent underlying infection or alveolar edema.
.
# CT HEAD W/O CONTRAST [**2107-4-1**] 12:16 AM
1. No acute intracranial pathology identified. Please note MRI
is more sensitive for evaluation of ischemia or lymphomatous
involvement.
2. Chronic appearing sinus changes with suggestive element of
acute sinusitis involving the left maxillary sinusitis. This
should be correlated with clinical exam.
.
# CHEST (PORTABLE AP) [**2107-4-1**] 3:33 AM
Mild interval improvement of bilateral airspace opacities.
Brief Hospital Course:
72M h/o secondary AML, admitted with respiratory failure s/p
transfusion and blast crisis.
.
# Hypoxic respiratory failure: Pt developed acute respiratory
decompensation after receiving blood products, raising the
concern for TRALI, transfusion-associated cardiac overload [**2-5**]
acute diastolic CHF, progressive AML with leukostasis,
overwhelming infection 2/2 blood products received, or PNA, with
the first two etiologies considered most likely. Pt was
maintained on ARDS Net protocol while intubated, with VAP
prevention, and was covered empirically with vancomycin,
ceftazidime, and levofloxacin for PNA. Cultures were pending
for blood products received at OSH; blood and urine cultures
were negative or pending during admission. Pt was extubated
without incident, and maintained on face tent with good oxygen
saturations. His family was very clear that they wished to
proceed with hospice care. He was therefore made CMO. He
subsequently developed increased dyspnea and hypoxemia
(uncertain etiology; perhaps leucostasis) and expired.
.
# Hypotension: Likely underlying etiologies considered were
systemic inflammatory response syndrome, sepsis [**2-5**] PNA or
transfusion-related infection, or cardiogenic shock [**2-5**] NSTEMI
given pt's h/o CAD. Pt was maintained on pressors initially but
was weaned off. Echocardigram demonstrated focal wall motion
abnormality, with rising cardiac enzymes. Given pt's low
platelets, aspirin was not administered; as pt was hypotensive,
beta blockers were also held.
.
# Tumor lysis syndrome: Given pt's high phosphate, worsening
creatinine, and hyperuricemia, initial concern was for tumor
lysis syndrome. Pt was hydrated with bicarbonate added to
alkalinize urine, and was started on rasburicase, with
hematology/oncology following.
.
# Acute on chronic renal failure: Immediate etiology considered
was uric acid nephropathy given pt's high uric acid. No
remarkable casts or crystals were noted on urine sediment.
Hemodialysis was held absent active indication. Creatinine
improved throughout admission with gentle hydration with added
bicarb and rasburicase.
.
# DIC: Initial concern raised for DIC given low platelets and
elevated coags, but no schistocytes were apparent and DIC labs
were negative. Platelets were transfused to maintain
10,000-20,000.
.
# Transaminitis: Elevated LFTs were noted with unclear etiology;
underlying causes considered were tumor infiltrate of liver
given pt's possible hepatomegaly on exam. RUQ ultrasound was
held given pt's non-cholestatic picture, and LFTs were trended.
.
# Blast crisis: Pt was noted to have WBC elevated to 165,
indicating likely acute blast crisis. Given pt's deteriorated
mental status as well as his oncologic prognosis, the decision
was made to not intervene with any acute therapies. Pt was
therefore made CMO.
.
# Mental status: Pt was noted to have altered mental status,
absent response to noxious stimuli, and absent responsiveness
after extubation. CT head and C-spine were negative for acute
pathology. Concern was for significant neurologic involvement
of AML. The decision was made to not intervene with any acute
therapies, and pt was made CMO.
Medications on Admission:
# Epoetin alfa weekly
# HCTZ 25mg daily
# Dutasteride (Avodart) 0.5mg daily
# Tamsulosin (Flomax) 0.4mg daily
# Esomeprazole 40mg daily
# Glipizide 10mg daily
# Insulin
# Vit D/Calcium
# Vitamin C
# Cyclosporine ophthalmic emulsion (Restasis)
# Bupropion (Wellbutrin) 100mg
# Eszopiclone (Lunesta) 2mg daily
# Gabapentin 600mg daily
# Acetaminophen PRN
# Celecoxib (Celebrex) 200mg
# Oxycodone PRN
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis
.
# Transfusion-related acute lung injury
# Transfusion-associated cardiac overload [**2-5**] acute diastolic
congestive heart failure
# Blast crisis [**2-5**] secondary acute myeologenous leukemia
# Non-ST elevation myocardial infarction
# Acute on chronic renal failure [**2-5**] uric acid nephropathy
# Respiratory failure [**2-5**] cardiac arrest
.
Secondary diagnosis
.
# Diabetes mellitus type 2
# Benign prostatic hypertrophy
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2107-4-4**]
|
[
"250.40",
"205.00",
"518.5",
"284.1",
"585.9",
"584.9",
"600.00",
"518.7",
"403.90",
"428.0",
"785.59",
"410.71",
"250.60",
"357.2",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7835, 7844
|
4169, 7012
|
347, 412
|
8338, 8347
|
2565, 4146
|
8403, 8569
|
2045, 2126
|
7803, 7812
|
7865, 8317
|
7381, 7780
|
8371, 8380
|
2141, 2546
|
274, 309
|
440, 1562
|
7027, 7355
|
1584, 1839
|
1855, 2029
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,018
| 173,482
|
53360
|
Discharge summary
|
report
|
Admission Date: [**2156-6-23**] Discharge Date: [**2156-7-4**]
Date of Birth: [**2078-6-1**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14145**]
Chief Complaint:
symptomatic bradycardia likely [**12-22**] flecanide toxicity -> sinus
arrest
Major Surgical or Invasive Procedure:
Pacemaker
History of Present Illness:
Pt 78 y/o female PMHx sig for Afib, HTN, Renal artery stenosis
with generalized weakness, dizziness today at home, found by EMS
to have pulse of 27, given atropine 1mg and pulse upto 44. Pt
never c/o CP, syncope, but made herself lie on the ground - no
fall or LOC. Pt was taken to OSH and HR 30s, pt given atropine
1mg x1 and HR upto 40s. BP stable. Pt transferred to [**Hospital1 18**] ED at
request of primary cardiologist, Dr. [**Last Name (STitle) **]. EKG shows no atrial
activity with ventricular escape @ 40s, otherwise BP stable but
some confusion, SOB.
In EW pt c/o SOB, weakness. No CP. Hr was 41, given atropine
went upto 52
Past Medical History:
HTN,
[**2145**] NQWMI,
Waldenstrom macrolobulinemia,
A fib on coumadin,
Renal A stenosis failed RA stent 2-3mos. ago,
Excercise induced VT
Social History:
Married
60 pack year hx of smoking, quit 1 year ago
etoh use: none
Family History:
non-contributory
Physical Exam:
HR 41 RR 14 T 100.8 BP 180/66 O2 99% on NRB
Gen: Pt confused, not orientated
Heent: Pupils dialated b/l, oral mucosa clear
Neck: JVD 8cm
Lungs: + crackles
Cardio: Bradycardic, S1/S2 no m/g/r
Abd: soft NTND NABS
Ext: +1 edema, trace DP
Pertinent Results:
[**2156-6-23**] 11:46PM TYPE-ART TEMP-37.2 PO2-146* PCO2-39 PH-7.38
TOTAL CO2-24 BASE XS--1
[**2156-6-23**] 11:46PM K+-3.9
[**2156-6-23**] 11:46PM freeCa-1.08*
[**2156-6-23**] 11:24PM POTASSIUM-3.9
[**2156-6-23**] 11:24PM MAGNESIUM-1.8
[**2156-6-23**] 09:03PM TYPE-ART TEMP-37.2 PO2-104 PCO2-35 PH-7.41
TOTAL CO2-23 BASE XS--1 COMMENTS-AXILLARY
[**2156-6-23**] 07:34PM TYPE-ART PO2-61* PCO2-33* PH-7.41 TOTAL
CO2-22 BASE XS--2
[**2156-6-23**] 07:34PM LACTATE-1.3
[**2156-6-23**] 07:34PM freeCa-1.09*
[**2156-6-23**] 03:22PM UREA N-53* CREAT-2.5* POTASSIUM-3.4
[**2156-6-23**] 03:22PM MAGNESIUM-1.9
[**2156-6-23**] 03:22PM HCT-22.8*
[**2156-6-23**] 03:22PM PLT COUNT-235
[**2156-6-23**] 02:57PM PT-15.5* INR(PT)-1.6
[**2156-6-23**] 02:52PM URINE HOURS-RANDOM UREA N-137 CREAT-23
[**2156-6-23**] 02:52PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2156-6-23**] 02:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-6-23**] 02:52PM URINE EOS-NEGATIVE
[**2156-6-23**] 07:53AM TYPE-ART PO2-64* PCO2-28* PH-7.39 TOTAL
CO2-18* BASE XS--6
[**2156-6-23**] 06:12AM GLUCOSE-146* UREA N-52* CREAT-2.4* SODIUM-133
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-17* ANION GAP-21*
[**2156-6-23**] 06:12AM CK(CPK)-79
[**2156-6-23**] 06:12AM CK-MB-NotDone cTropnT-<0.01
[**2156-6-23**] 06:12AM CALCIUM-8.2* PHOSPHATE-4.8* MAGNESIUM-2.1
IRON-36
[**2156-6-23**] 06:12AM calTIBC-186* FERRITIN-147 TRF-143*
[**2156-6-23**] 06:12AM WBC-13.8*# RBC-2.47* HGB-8.2* HCT-24.2*
MCV-98 MCH-33.2* MCHC-34.0 RDW-12.6
[**2156-6-23**] 06:12AM PLT COUNT-269
[**2156-6-23**] 06:12AM PT-16.8* PTT-39.8* INR(PT)-1.9
[**2156-6-23**] 06:12AM RET AUT-1.3
[**2156-6-23**] 12:12AM TYPE-ART PO2-70* PCO2-32* PH-7.38 TOTAL
CO2-20* BASE XS--4
[**2156-6-23**] 12:12AM LACTATE-1.5
[**2156-6-22**] 08:00PM GLUCOSE-137* UREA N-48* CREAT-2.4*#
SODIUM-132* POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-17* ANION
GAP-19
[**2156-6-22**] 08:00PM CK(CPK)-59
[**2156-6-22**] 08:00PM CK-MB-NotDone
[**2156-6-22**] 08:00PM cTropnT-<0.01
[**2156-6-22**] 08:00PM TRIGLYCER-84
[**2156-6-22**] 08:00PM OSMOLAL-283
[**2156-6-22**] 08:00PM PHENYTOIN-<0.6*
[**2156-6-22**] 08:00PM WBC-8.6 RBC-2.67* HGB-8.6* HCT-25.7* MCV-96
MCH-32.3* MCHC-33.6 RDW-12.6
[**2156-6-22**] 08:00PM PLT COUNT-253
[**2156-6-22**] 08:00PM PT-16.8* PTT-39.3* INR(PT)-1.9
[**2156-6-22**] 08:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2156-6-22**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2156-6-22**] 08:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
Echo: EF > 60% The left atrium is mildly dilated. The right
atrium is moderately dilated. Moderate (2+) mitral regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension
Brief Hospital Course:
1) Bradycardia - sinus arrest but qrs narrowed and p waves
returned as flecanide wore off, symptomatic with
confusion/CHF/weakness, possible etiology from poor renal
clearence of flecainide and BB, r/o'ed out for MI. Pt eventually
restarted on metoprolol and rate returned to [**Location 213**]. Pt had
pacemaker placed to prevent bradycardia.
2) Afib - Pt had a few episodes of WCT which appeared to be A.
fib. Pt bounced back and forth from WCT to bradycardia and then
HR eventually stabalized. Pt remained in A.fib (narrow
complex). Once pacemaker pt started on amiodorone. Pt was to
get cardioversion but Afib spontaneously converted with
amiodorone. Pt started on heparin drip which was eventually
bridged with warfarin. Pt was sent home on warfarin and
lovenox.
2) CHF due to diastolic dysfxn w/ pulm edema causing hypoxia-
hypertensive. TTE showed a normal EF (60%). Pt initially given
lasix and metolazone for diureses and then switched to natrecor
which caused her to diurese. CXR initially was consistent with
pulmonary edema. Pt blood pressure during hospital stay
remianed high so pt started on nitroprusside drip and IV
hydralazine for afterload reduction. Natrecor was stopped and
pt was weaned off nitroprusside and started on oral hydralazine
and isordil. Htn medication simplified to isordil, metoprolol,
and norvasc and hydralazine.
3) Renal Failure - chronic w/ RAS s/p failed stent. Cre on
admission was as high as 2.4 but began to trend down throughout
hospital course.
4) Anemia - likely secondary to CRI and Waldestrom's. Guaiac
(-), continued to guaiac stools. Pt got 2 units of blood and
iron workup was consistent for anemia of chronic disease.
5) Confusion - ? Delerium from hypoxia vs. Atropine. multiple
medical conditions. agitated and difficult to oxygenate, used
ativan to control pt agitation. Pt got head CT which showed no
acute bleed. Pt was eventually weaned off ativan. Py mental
status returned to baseline during hospital course.
6) leukocytosis and fever. Pt was given Vanc/Levo for possible
aspiration pna. CXR suggested possible aspiration PNA in LLL.
Blood cultures and urine cultures sent. Pt WBC returned to
[**Location 213**] value while in hospital. Pt finished course of
antibiotics while in hospital.
Medications on Admission:
Metroprolol 25 [**Hospital1 **],
Flecainide 100 [**Hospital1 **],
Lipitor 10,
Norvasc 10 [**Hospital1 **],
Cozaar 50 [**Hospital1 **],
Hydralazine 50 tid,
coumadin 4mg,
Dilantin 100 [**Hospital1 **],
KCL,
Meclizine,
folate,
tylenol,
diazide 37.5/25
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: [**11-21**] Inhalation Q6H
(every 6 hours) as needed.
2. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO QD (once
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydralazine HCl 50 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours).
Disp:*135 Tablet(s)* Refills:*2*
7. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1)
Subcutaneous Q24H (every 24 hours).
Disp:*2 80mg/0.8ml* Refills:*2*
8. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at bedtime
for 1 doses.
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Diversified Home Services Hospice
Discharge Diagnosis:
Sinus Arrest
Atrial Fibrillation
Discharge Condition:
Good
Discharge Instructions:
Please have your blood checked on [**7-5**] to determine if INR in
range to determine if lovenox shot can be stopped. Continue to
take lovenox shot until INR in theraputic range. Continue to
take coumadin until told to stop by cardiologist. Please follow
up at device clinic on [**2156-7-6**] to have pacemaker checked and to
be setup with a cardiologist at new location. Please follow up
with Dr. [**Last Name (STitle) **] in 1 week
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2156-7-6**] 9:30
Please have blood and INR checked on [**2156-7-5**] and fax results to
Dr. [**Last Name (STitle) **] to determine if lovenox shot can be stopped.
Please follow up with Dr. [**Last Name (STitle) **] in 1 week.
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,504
| 186,034
|
41925
|
Discharge summary
|
report
|
Admission Date: [**2101-11-29**] Discharge Date: [**2101-12-3**]
Date of Birth: [**2070-11-4**] Sex: M
Service: MEDICINE
Allergies:
Honey
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Upper Endoscopy with variceal banding
Liver biopsy
Blood transfusion
History of Present Illness:
31-year-old man with no prior history of cirrhosis was in his
usual state of health until [**2101-11-27**]. He then had nausea and
large volume hematemesis. He syncopized and family called EMS.
He was taken to [**Hospital3 417**] Hospital. In the ED patient was
alert and oriented without any complaints of abdominal pain,
chest pain or shortness of breath, fever or chills. An NGL was
performed with resulting 600cc bright red blood. He eventually
cleared after second lavage. Patient was hypotensive with a
systolic of 92 and tachycardic to 110. Hct 24. given protonix
bolus, octreotide bolus and crossed for 4 units of pRBC. He was
transferred to MICU at OSH, where he received 5u pRBC. EGD was
performed showing grade III/IV esophageal varices at GE
junction, gastric cardia varices, moderate-to-severe portal
hypertensive gastropathy. 6 bands were done. After banding, pt
had repeat 500 cc emesis. Given 2 more units pRBC and was
continued on protonix and octreotide.
.
Pt was intubated for airway protection and transferred to [**Hospital1 18**]
MICU on 100 mcg fentanyl, 4 mg versed, protonix gtt, octreotide
gtt, IV NTG. On arrival to the MICU, the patient was intubated
but was arousable and oriented. He acknoledges abdominal pain
but can not localize. Pt was extubated without incident later
that day. He has remained stable and only received 1 x pRBC on
[**11-30**] for slowly decreasing Hct. Pt was tolerating regular diet
and was transferred to the floor on [**2101-12-1**].
.
Pt states that prior to the event, he had 2-3d of decreased
appetite. Otherwise, he felt completely fine. No discomfort or
pain at all. No fevers, no chills, no night sweats, no
weightloss. No dysphagia, no nausea or vomiting aside from
single episode on [**2101-11-27**], no chest pain or SOB. No
palpitations. No diarrhea or constipation. No urinary problems.
Past Medical History:
None. Never hospitalized. No operations.
Social History:
Pt was born in [**Country 16465**] and lived in a well-developed part of
[**Location (un) 48047**] for most of his life. He did live on a farm in rural
[**Country 16465**] for 5 years from ages [**1-7**] (cattle, chickens). Pt does
not recall any fresh-water exposure aside from chlorinated
pools. Never swam in rivers, lakes, or ponds. Pt came to the
United States in [**2090**] as a student. Currently works as a car
salesman. Denies any exposure to caustic chemicals. Pt has not
been back to [**Country 16465**] since [**2090**]. He receives spices, tea, and
coffee from [**Country 16465**] but no meat or dairy products.
-Alcohol: used to binge drink [**8-30**] drinks on weekends fur ~2
years [**2094-5-22**]. Now ~2 drinks weekly.
-Tobacco: ~7 pack year history of smoking, including 1 pack q2-3
days now.
-Drugs: denies. No IV drug use
-Sex: has had multiple female partners but generally uses
condoms. Last STD check including HIV was in early [**2101**], all
negative. Pt denies any unprotected sex since.
Family History:
-Mother: diabetes mellitus
-Father: hypertension
-3 brothers, 1 was diagnosed with peptic ulcer in [**Country 16465**] in his
20s (no scope, no studies, no labs). 2 other brothers healthy.
-Uncle: lung cancer in 50s, heavy smoker.
Physical Exam:
Admission Exam:
Vitals: T:100.4 BP:137/71 P:91 R: 18 O2:100
General: Intubated, Arousable to verbal stimuli
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, hyperactive bowel
sounds present, no organomegaly, no ascites
GU: foley in place with clear urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:Patient moving all 4 extremities, 2+ reflexes bilaterally,
gait deferred
Physical Exam:
Vitals: Tm 99.6, Tc 98,1m 100-115, 55-64, 78-87, 18, 99%RA
General: well appearing young man in no apparent distress
HEENT: PERRL, EOMI, normal oropharynx, no LAD, sclera anicteric
Neck: no JVD
CV: RRR, nl s1, s2, no m/r/g
Lungs: CTAB
Abdomen: normal bowel sounds, soft, non-tender.
Ext: no edema, 2+ pulses dp and radial
Neuro: CN2-12 intact, 5/5 strength bilaterally, normal sensation
bilaterally
Pertinent Results:
[**2101-11-29**] 12:35AM BLOOD WBC-8.0 RBC-3.36* Hgb-9.8* Hct-28.7*
MCV-86 MCH-29.2 MCHC-34.2 RDW-15.4 Plt Ct-81*
[**2101-11-29**] 12:35AM BLOOD Neuts-77.0* Lymphs-15.7* Monos-6.1
Eos-1.1 Baso-0.1
[**2101-11-29**] 12:35AM BLOOD PT-15.2* PTT-25.3 INR(PT)-1.3*
[**2101-11-29**] 12:35AM BLOOD Glucose-125* UreaN-26* Creat-0.9 Na-144
K-3.9 Cl-114* HCO3-22 AnGap-12
[**2101-11-29**] 12:35AM BLOOD ALT-34 AST-40 LD(LDH)-150 AlkPhos-22*
TotBili-0.5
[**2101-11-29**] 12:35AM BLOOD Albumin-3.3* Calcium-7.2* Phos-2.3*
Mg-1.6
[**2101-11-29**] 02:07AM BLOOD Type-ART Temp-38.0 Rates-12/ Tidal V-500
PEEP-5 FiO2-40 pO2-197* pCO2-46* pH-7.32* calTCO2-25 Base XS--2
Intubat-INTUBATED
[**2101-11-29**] 12:47AM BLOOD Lactate-1.3
[**2101-11-29**] 12:47AM BLOOD freeCa-1.06*
[**2101-11-29**] 03:36AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2101-11-29**] 03:36AM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
[**2101-11-29**] 03:36AM URINE RBC-55* WBC-9* Bacteri-NONE Yeast-NONE
Epi-0
[**2101-11-29**] 12:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2101-11-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2101-11-29**] 12:35AM BLOOD Ferritn-46
[**2101-11-29**] 12:35AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2101-11-29**] 12:35AM BLOOD HCV Ab-NEGATIVE
[**2101-11-29**] 02:53AM BLOOD Smooth-POSITIVE *
[**2101-11-29**] 02:53AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2101-11-29**] 10:41AM BLOOD CERULOPLASMIN-20 (normal)
[**2101-11-29**] 02:53AM BLOOD SCHISTOSOMA ANTIBODIES-not detected
[**2101-11-29**] Pathology Tissue: RUSH LIVER BX.
Liver, needle core biopsy: 1. Congenital hepatic fibrosis with
nodule formation and extensive fibrosis. 2. No significant
portal or lobular inflammation is seen. 3. No steatosis seen. 4.
Trichrome stain confirms extensive fibrosis. 5. Iron stain shows
no stainable iron.
[**2101-11-29**] Radiology DUPLEX DOPP ABD/PEL
FINDINGS: The liver demonstrates no focal or textural
abnormality. There is no biliary dilatation. The common duct is
2 mm. The gallbladder appears unremarkable, without stone, wall
thickening, or pericholecystic fluid. There is umbilical vein
recanalization. The spleen is enlarged to 16 cm. A moderate
abdominal ascites is present. Color Doppler son[**Name (NI) **] was
performed, demonstrating patent SMV, splenic vein, and IVC.
There are appropriate arterial and venous waveforms in the
hepatic veins, main, left, and right portal veins, and hepatic
arteries. IMPRESSION: 1. Normal son[**Name (NI) 493**] appearance of the
liver. 2. Umbilical vein recanalization, splenomegaly, and
ascites, consistent with portal hypertension. 3. No gallbladder
abnormality. 4. Patent hepatic vasculature.
[**2101-11-30**] Radiology CHEST (PORTABLE AP)
Bilateral lungs are adequately expanded and there is no opacity
concerning for pneumonia or aspiration. Top normal heart size,
mediastinal and hilar contours are normal. There is no pleural
effusion. IMPRESSION: No evidence to suggest
pneumonia/aspiration.
[**2101-12-1**] Radiology CT ABD W&W/O C
CT ABDOMEN AND PELVIS: MDCT imaging was performed from the lung
bases to the pubic symphysis in non-contrast, portal venous, and
10-minute delayed phases. This imaging was performed only
through the abdomen. Sagittal and coronal reformats were
performed. COMPARISON: Liver ultrasound, [**2101-11-29**].
FINDINGS: Small bilateral pleural effusions with minimal
adjacent atelectasis are present. The partially visualized heart
appears normal. The spleen is enlarged measuring 16 cm. The
adrenal glands appear normal. Numerous low-attenuation lesions
are present in bilateral kidneys, however, in the upper pole of
the left kidney is a 2.3 x 1.1 cm lesion with internal high
attenuation septa. In the right kidney is a simple-appearing
partially exophytic 2.5 x 1.5 cm cyst. The pancreas appears
normal. The gallbladder appears normal. The liver has a nodular
contour and the right lobe of the liver is small, but the
caudate is hypertrophied. No discrete liver lesions are
identified. The portal venous system is patent, but there is
recanalization of a paraumbilical vein (4:25). A
small-to-moderate amount of ascites is present. No free air is
present. No significant adenopathy is present in the abdomen. A
possible encapsulated lipoma measuring 2.3 x 1.1 cm is present
adjacent to the pancreatic tail (4:29). The abdominal aorta and
its branches appear normal. Stomach and abdominal loops of bowel
appear normal; however, there are likely esophageal and gastric
varices. BONE WINDOWS: No suspicious bone lesions are
identified. IMPRESSION: 1. Cirrhotic liver with evidence for
portal hypotension with recanalization of paraumbilical vein and
splenomegaly. No liver lesions identified, however. 2.
Small-to-moderate amount of ascites. 3. Left upper pole renal
lesion which appears to have thick septations and an MRI of the
kidney should be performed to better evaluate and exclude
malignancy. ADDENDUM: The Bosniak classification for the earlier
described left upper pole lesion with thick septations would be
a Bosniak classification III. MRI should be performed to further
evaluate.
Brief Hospital Course:
31 yo previously healthy male transferred from OSH after acute
large volume hematemesis, then found to have portal hypertension
of unclear etiology and severe esophageal and gastric varices,
stable after banding.
.
# UGIB: hemodynamically stable, but has received a total of 7
units pRBC. Likely from severe esophageal and gastric varices as
seen on OSH EGD. He underwent banding; however, has developed
500 cc hematemesis subsequently and was transferred to [**Hospital1 18**] for
further care. Pt was initially transferred from OSH ICU to [**Hospital1 18**]
ICU. He was initially intubated at the OSH to protect his
airway, and he was extubated without issue on [**11-29**]. Pt had a
liver biopsy performed on [**11-29**]. Octreotide drip was started
[**11-29**] and stopped [**12-3**] morning. Pt was also treated with
ceftriaxone 1g iv q24h ([**11-30**]/-[**12-3**]), Pantoprazole 40 mg IV
Q12H, and sucralfate 1mg qid. Pt was very stable clinically
throughout his admission, and he was started on nadolol 40mg
daily. Etiology of Pt's portal hypertension was initially
unclear. [**Name2 (NI) **] differential of cirrhosis included alcoholic,
Wilson's, hep b/c, autoimmune and non-cirrhotic causes Schisto,
multiple prior infections, congenital. Toxin screen was
negative. Ferritn was normal at 46. Ceruloplasmin was normal at
20 and no Kayser Fleischer rings per Ophtho. Hep B sAg negative,
Hep B sAb negative. Hep C sAb negative. [**Doctor First Name **] was negative,
Schistosomal IgG was not detected. The only serology that was
positive was anti-smooth muscle Ab at 1:20 titer. Final
pathology showed congenital hepatic fibrosis. On CT abdomen,
multiple renal lesions were noted. Given congenital hepatic
fibrosis, suspect renal lesions may be due to polycystic kidney
disease (see below). Ascites was also noted on imaging, and Pt
also started on furosemide 20mg daily and spironolactone 50mg
daily. Pt will need repeat EGD in one month, and he has been
schedule for liver follow-up at [**Hospital1 18**].
.
# Multiple renal lesions: Pt has "numerous" bilateral renal
lesions seen on CT, including one lesion on L upper pole
concerning for possible malignancy, Bosniak criteria 3. Given
congenital hepatic fibrosis seen on biopsy, suspect polycystic
kidney disease. However, no family history. Pt is young for
ADPKD but old for ARPKD. Nephrology was consulted and agreed
with potential diagnosis of polycystic kidney disease.
Recommended 24 hr urine, cr, urea, protein, and followup in
outpatient nephrology clinic with outpatient MRI w/ contrast of
kidney to r/o malignancy.
.
#Fever: Patient had no evidence of infection at the OSH. He did
not have any leukocytosis. Brief fever to 101F on [**11-29**]. Unclear
etiology. Pt was started on ceftriaxone 1g iv daily for SBP
prophylaxis in the setting of acute GI bleed. Pt has been
afebrile since. Per ICU, no easily accessible pocket of ascites
for tap. Blood cx showed no growth. UA 55 RBCs, 9 WBCs, no
bacteria (w/ foley). CXR showed no evidence to suggest pneumonia
or aspiration. Pt remained afebrile for the rest of his course.
.
TRANSITIONAL ISSUES:
-Pt will need close GI/Liver follow-up given his severe portal
hypertension and potential for bleeds. He will need repeat EGDs
in the near future to control and monitor any significant
varices.
-Pt will need renal follow-up for polycystic kidney disease
including outpatient MRI to rule out malignancy in L upper pole
mass.
-If Pt has polycystic kidney disease, Pt may need additional
testing such as MRA head to look for aneurysms, and genetic
counseling.
-Given hypersplenism, Pt was instructed to avoid contact sports.
Medications on Admission:
None. No herbals, no supplements.
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day for 10 days.
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO twice a day
for 4 weeks.
Disp:*60 Tablet(s)* Refills:*2*
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
5. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
congenital hepatic fibrosis
portal hypertension
variceal bleed
? polycystic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 91022**],
You initially went to [**Hospital3 417**] Hospital after having a
sudden episode of large volume bloody vomiting. You had an
emergent upper endoscopy during which you were found to have
many varices (dilated blood vessels) in your esophagus and
stomach, and very high pressure in the blood vessels of your
abdomen (the portal system). Several bands were placed, and you
were started on medications to stop the bleeding. You were also
given many units of blood. You had a breathing tube placed to
protect your airway. You had a second bleed, and you were
transferred to [**Hospital1 18**] for further care. Your blood levels were
stable here, and your breathing tube was removed. You had a
liver biopsy here, which showed that you have a condition called
congenital hepatic fibrosis. This is condition, which you have
had sincee birth, causes changes in the architecture of your
liver, which makes it difficult for blood to flow through it.
This causes the pressure of the blood vessels of your abdomen
(the portal system), and especially in your lower esophagus or
stomach, to be very high, which causes the vessels to buldge and
dilate. When these become too large, one may burst, you may have
a lot of bleeding, such as you experienced. In order to prevent
further bleeding, you will need to continue nadolol, the
medication that lowers the pressure in your blood vessels. You
will also need to have repeat upper endoscopies (EGD) in order
to ensure that your varices are not getting bigger and to have
additional banding done if necessary. We have scheduled a repeat
upper endoscopy for you next month (see below). The increased
portal system pressure also causes your spleen, an organ that
helps clear infections from the blood, to become very large. A
normal spleen is 11 cm; yours is currently 16 cm. Because the
spleen is a very blood-filled and soft organ, it is easy to
damage when it becomes enlarged. You will need to avoid contact
sports and be very careful during other activites to avoid
rupturing your spleen, which may cause severe internal bleeding.
The increased pressure of the portal system also leads to fluid
build up in the abdomen, which you have already begun to
experience. We have started you on two medications, furosemide
(Lasix), and spironolactone (Aldactone), which you should
continue. These will help eliminate excess fluid from your body.
Your liver condition is also associated with a kidney disease
call Polycystic Kidney Disease. On CT imaging of your abdomen,
we found that you have many cyst-like lesions on both of your
kidneys. You were seen by our kidney specialists
(nephrologists), who feel that you likely have a variant called
Autosomal Dominal Polycystic Kidney Disease. ****You will need
further imaging and tests.***** Patients with polycystic kidney
disease often also develop bloody urine, repeated urinary tract
infections. We have made an appointment for you to see our
polycystic kidney specialist as an outpatient to discuss these
issues.
We have made the following changes to your mediations:
-Start nadolol 40 mg tablets, 1 tab daily
-Start pantoprazole 40mg tablets, 1 tab daily for 1 week
-Start sucralfate 1gm tablets, 1 tab twice daily for 4 weeks
-Start furosemide 20mg tablets, 1 tab daily
-Start spironolactone 50mg tablets, 1 tab daily
We have made several appointments for you. It is very important
that you please keep these appointments. If you cannot make your
appointment, please call and reschedule.
Followup Instructions:
You will need an MRI of your kidneys. Please call [**Telephone/Fax (1) 327**]
to schedule one at your convenience
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Department: Internal Medicine
Address: 125 [**First Name9 (NamePattern2) 91023**] [**Location (un) 86**], [**Numeric Identifier 6422**]
Phone: [**Telephone/Fax (1) 91024**]
Appointment: Friday [**2101-12-9**] 2:15pm
Department: GI-WEST PROCEDURAL CENTER
When: FRIDAY [**2101-12-23**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: LIVER CENTER
When: THURSDAY [**2102-1-5**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital 9380**] CLINIC
When: TUESDAY [**2102-1-10**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
Completed by:[**2101-12-6**]
|
[
"537.89",
"456.20",
"789.59",
"572.3",
"305.1",
"753.14",
"780.60",
"285.1",
"456.8",
"571.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
14215, 14221
|
9891, 12985
|
280, 375
|
14365, 14365
|
4660, 9868
|
18049, 19547
|
3369, 3602
|
13613, 14192
|
14242, 14344
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|
14516, 18026
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4240, 4641
|
13006, 13529
|
229, 242
|
403, 2257
|
14380, 14492
|
2279, 2321
|
2337, 3353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,287
| 134,920
|
44340
|
Discharge summary
|
report
|
Admission Date: [**2199-12-10**] Discharge Date: [**2199-12-19**]
Date of Birth: [**2149-7-11**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
intubation / mechanical ventilation
peritoneal dialysis catheter placement
History of Present Illness:
Pt is a 50F w/PMHx of T1DM, HTN, stage V ESRD, and renal artery
stenosis with left renal artery stenting, who was brought to the
[**Hospital 794**] hospital by EMS after several days of nausea and vomiting
complicated by dyspnea. Per report, she was found by a family
member in significant respiratory distress and EMS was called.
In the emergency department at OSH, she was found to be
hypertensive with SBPs to the 230s, with chest x-ray suggestive
of pulmonary edema (although it was also thought that it could
be consistent with either ARDS or pneumonia), and was
subsequently intubated. She was also found to have a
bun/creatinine of 73/8.09, a BNP greater than 5000, troponin of
2.84, and WBC 26K. The patient's hypertension was treated with
nitroglycerin gtt, hydralazine, and labetalol. Given the
possibility of pneumonia, she was given ceftriaxone,
azithromycin, and zosyn. She was also given rectal ASA due to
her significantly elevated troponin.
.
In the OSH ICU, the patient remained intubated, with vitals T
97.6, BP 153/77 p 100, SO2 100% on 50% FiO2. Her hypertension
was controlled with a nitroglycerin drip. Given her significant
leukocytosis and possible pneumonia on chest x-ray, she was also
treated for pneumonia with azithromycin and vancomycin. An ECG
demonstrated Q-waves in leads V1-V3. An ECHO was performed which
demonstrated significantly impaired LV function with an EF of
20-25% (her previous ECHO in [**2194**] demonstrated normal LV size
and systolic function. Borderline concentric LVH. Visually
estimated EF ~ 65-70%). Although diuresis was attempted, she
experienced no significant improvement in breathing (lasix
120mg, metolazone, and Bumex all tried without success). A
transfer to the [**Hospital1 18**] MICU was requested by the patient's
family.
.
On arrival to the MICU, the patient was intubated, with vital
signs of : T 37.4, p 91, bp 166/78, on CPAP/PSV of 15/5, with
respirations 23, on FiO2 of 40%.
Past Medical History:
- IDDM
- ESRD V, GFR < 15ml/min, thought to be due to DM
- Diabetic retinopathy
- MDD
- renal artery stenosis with left RA stenting
- Hypertension goal BP (blood pressure) < 130/80
- Hyperlipidemia LDL goal
- Bilateral carotid stenosis
- Anemia in chronic kidney disease
Social History:
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
mother: living
father: deceased, htn
Physical Exam:
Admission exam
T 37.4, p 91, bp 166/78, on CPAP/PSV of 15/5, with respirations
23, on FiO2 of 40%
General: Intubated, sedated, opens eyes to voice but not
following commands.
HEENT: PERRL, anicteric sclera, ETT in place.
CV: S1S2 RRR w/o m/r/g??????s. No heave.
Lungs: CTA bilaterally w/ mild dependent crackles, no wheezing.
Ab: Positive BS??????s, NT/ND, no appreciable HSM.
Ext: No c/c/e.
Neuro: As above, sedated, but opens eyes to voice. Not following
commands or interacting. Moving all extremities.
Discharge exam
VS: 97.7 130/50 (130/50-168/60) 63 (64-77) 18 96% RA
I/O: [**Telephone/Fax (1) 25871**]
GEN: Well appearing woman in NAD
HEENT: sclera anicteric, MMM
LUNGS: CTAB, no wheezes or crackles
HEART: RRR, nl S1-S2. 2/6 systolic murmur heard throughout
ABDOMEN: NABS, soft/NT/ND, no rebound/guarding. peritoneal
catheter in place with dressing intact. minimal serosanguinous
drainage.
EXT: no LE edema
NEURO: A/Ox3
Pertinent Results:
Admisison labs
[**2199-12-10**] 06:25PM BLOOD WBC-22.7*# RBC-2.25*# Hgb-6.6*#
Hct-20.1*# MCV-89 MCH-29.4 MCHC-32.9 RDW-14.4 Plt Ct-309
[**2199-12-10**] 06:25PM BLOOD Neuts-86.6* Lymphs-4.4* Monos-7.1 Eos-1.6
Baso-0.2
[**2199-12-10**] 06:25PM BLOOD Fibrino-595*
[**2199-12-11**] 03:35AM BLOOD Ret Aut-1.9
[**2199-12-10**] 06:25PM BLOOD Glucose-198* UreaN-82* Creat-7.8*# Na-139
K-3.9 Cl-100 HCO3-21* AnGap-22*
[**2199-12-10**] 06:25PM BLOOD ALT-21 AST-23 LD(LDH)-278* CK(CPK)-393*
AlkPhos-74 TotBili-0.2
[**2199-12-10**] 06:25PM BLOOD CK-MB-6 cTropnT-0.51* proBNP-GREATER TH
[**2199-12-10**] 06:25PM BLOOD Albumin-3.2* Calcium-8.7 Phos-7.0* Mg-2.4
Iron-18*
[**2199-12-10**] 06:25PM BLOOD calTIBC-215* Ferritn-86 TRF-165*
[**2199-12-10**] 06:25PM BLOOD Acetone-NEGATIVE
[**2199-12-10**] 06:25PM BLOOD TSH-0.37
[**2199-12-10**] 06:25PM BLOOD HCG-<5
[**2199-12-11**] 03:35AM BLOOD Vanco-33.1*
[**2199-12-10**] 06:30PM BLOOD Lactate-1.1
Discharge labs
[**2199-12-19**] 07:00AM BLOOD WBC-9.6 RBC-2.82* Hgb-8.7* Hct-26.4*
MCV-94 MCH-30.9 MCHC-33.0 RDW-13.5 Plt Ct-309
[**2199-12-19**] 07:00AM BLOOD Glucose-106* UreaN-86* Creat-9.0* Na-143
K-4.4 Cl-101 HCO3-31 AnGap-15
[**2199-12-19**] 07:00AM BLOOD Calcium-9.4 Phos-6.5* Mg-2.4
CXR ([**2199-12-16**]):
As compared to the previous radiograph, the pre-existing
bilateral
pleural effusion has completely resolved. There is no remnant
effusion or
pulmonary edema. Borderline size of the cardiac silhouette.
Normal hilar and mediastinal contours.
Brief Hospital Course:
Primary Reason for Admission: Pt is a 50F w/PMHx of T1DM, HTN,
stage V ESRD, and renal artery stenosis s/p left renal artery
stenting, who presents with respiratory distress thought to be
[**12-26**] flash pulm edema, severe HTN and acute on chronic kidney
injury.
.
Active Problems:
.
# RESPIRATORY DISTRESS: The patient presented in significant
respiratory distress in the setting of inability to tolerate POs
due to nausea and vomiting. Her systolic BP was 230 at the time,
and her respiratory failure was thought to be [**12-26**] flash
pulmonary edema due to BP medication non-compliance in the
setting of recent nausea and vomiting. She was intubated and
diuresed with 120mg IV Lasix with improvement in her pressures
and respiratory status. Ms. [**Known lastname 518**] was successfully extubated
on first hospital day and she was called out to the floor. She
remained stable on RA thereafter. At the time of discharge, she
was euvolemic and in no respiratory distress
.
# LEUKOCYTOSIS: Likely stress response from hypoxia and
intubation. No evidence of acute infection. Although
antibiotics were initially started, they were quickly
discontinued. Ms. [**Known lastname 518**] remained afebrile and her white
count continued to trend down and had normalized at the time of
discharge. Blood and urine cultures were negative and
respiratory viral culture was also negative.
.
# DKA: Patient with widening gap and ketonemia and ketonuria.
She was started on an insulin drip and her gap closed. [**Last Name (un) **]
was consulted for further recommendations. Her BG control
improved though she did have a persistent AG acidosis, which was
felt to be due to uremia. Later in her hospital course she
became hypoglycemic to as low as 20 likely in the setting of
being NPO with poor po intake in addition to poor clearance of
insulin. Her insulin regimen was adjusted and she was discharged
with plans to follow up with her PCP. [**Name10 (NameIs) **] would benefit from an
endocrinologist to follow her diabetes.
.
# CHRONIC KIDNEY DISEASE: Pt has stage V CKD due to chronic DM
and HTN and will require initiation of dialysis sometime in the
next few months. Renal was consulted and PD catheter placement
was agreed upon in accordance with the patients wishes. PD
catheter was placed on [**2199-12-18**]. Her medication regimen was
adjusted to include sevelemer, calcium acetate, and sodium
bicarbonate. She was started on torsemide and was euvolemic upon
discharge. Electrolytes were relatively stable. She was
discharged with plans to follow up with her nephrologist and the
PD nurse for teaching. She will follow up with [**Date Range **]
surgery within 1 week to evaluate her surgical site. She also
has plans to undergo workup for potential kidney [**Date Range **].
.
# CHF: At OSH, pt had TTE that showed EF 20%, concerning for
acute CHF exacerbation vs Takotsubo's, though no mention was
made of apical ballooning per report. Of note, this echo was
performed in the setting of hypertensive urgency/emergency and
acute respiratory failure, and therefore does not represent a
reliable baseline. Repeat TTE at [**Hospital1 18**] showed EF 40% with PCWP
>18mmHg and diffuse LV hypokinesis. She was diuresed with Lasix
120mg IV x1 and Torsemide 40mg po qday thereafter. She was
continued on Atorvastatin, ASA, Amlodipine, Labetalol and
Torsemide; [**Last Name (un) **] therapy was not initiated due to concern for
hyperkalemia in the setting of ESRD, consideration may be given
to starting once pt has started PD (pt had a cough on ACE-I).
She will likely need continued cardiology follow up and this
will be arranged at [**Location (un) 2274**].
.
# ELEVATED TROPONINS: Likely due to demand ischemia in setting
of acute stress and illness and acute on chronic renal failure.
No evidence of focal wall abnormalities on ECHO and no ST
changes on EKG. Patient's troponins were trended and were
stable, CKMB were normal.
.
Chronic Problems:
# ANEMIA: Likely anemia of chronic disease and decreased epo
production from kidney failure. Patient's hematocrits were
trended throughout admission.
.
Transitional Issues
- patient will need to meet with PD nurse for teaching
- patient will need to follow up with nephrology to discuss
initiation of dialysis
- patient will need to follow up with [**Location (un) **] surgery to
evaluate proper healing of surgical site
- patient will likely undergo workup for kidney [**Location (un) **]
- patient had labile blood sugars during admission and insulin
regimen will likely require further adjustment.
- patient will need cardiology follow up for her heart failure
- patient was full code on this admission
Medications on Admission:
Epoetin Alfa (PROCRIT) 20,000 unit/mL Injection Solution Inject
5000 unit (0.25ml) under the skin weekly - Started at last
clinic appt
Insulin Glargine (LANTUS) 100 unit/mL Subcutaneous Solution
Inject 30 units or as directed
Hydralazine 25 mg Oral Tablet 4 tabs (100mg) three times daily
Multivitamin Oral Capsule 1 by mouth once daily
Clonidine 0.1 mg Oral Tablet 2 tablet twice daily
Calcium Carbonate-Vitamin D3 (CALTRATE 600 + D) 600 mg(1,500mg)
-400 unit Oral Tablet, Chewable 1 tab daily
Furosemide 40 mg Oral Tablet Take 1 tablet twice daily
Aspirin 81 mg Oral Tablet, Chewable None Entered
Simvastatin 40 mg Oral Tablet take one tablet daily for high
cholesterol
Insulin Aspart (NOVOLOG) 100 unit/mL Subcutaneous Solution
Inject 2-10 units pre-meal according to sliding scale
Diltiazem HCl (CARDIZEM CD) 240 mg Oral Capsule, Ext Release 24
hr Take 2 capsules daily
Discharge Medications:
1. epoetin alfa Injection
2. multivitamin Capsule Sig: One (1) Capsule PO once a day.
3. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
Disp:*4 Patch Weekly(s)* Refills:*2*
4. Vitamin D Oral
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. labetalol 300 mg Tablet Sig: Two (2) Tablet PO three times a
day.
Disp:*180 Tablet(s)* Refills:*2*
9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 tablets* Refills:*2*
10. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Glucagon Emergency 1 mg Kit Sig: One (1) injection Injection
once a day as needed for hypoglycemia: use if severe
hypoglycemia and call 911.
Disp:*1 kit* Refills:*2*
12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
13. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
14. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*0*
15. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
16. insulin glargine 100 unit/mL Solution Sig: Twelve (12)
Subcutaneous at bedtime for 30 days.
Disp:*QS QS* Refills:*0*
17. Humalog 100 unit/mL Solution Sig: as directed by sliding
scale Units Subcutaneous four times a day: please take as
directed by attached sliding scale with meals and at bedtime.
Disp:*1 bottle* Refills:*0*
18. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: respiratory failure
secondary diagnoses: ESRD, hypertension, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 518**],
It was a pleasure caring for you while you were admitted to
[**Hospital1 18**]. You were transferred from an outside hospital after going
into respiratory failure thought to be due to your high blood
pressures. During your hospitalization, your medication regimen
was adjusted to improve your blood pressure and glucose control.
You were evaluated by the kidney doctors and the [**Name5 (PTitle) **] team
while you were here, and had a successful placement of a
peritoneal dialysis catheter.
The following changes have been made to your medication regimen:
Please START taking
- labetalol
- clonidine patch
- amlodipine
- lipitor
- calcium acetate
- nephrocaps
- sodium bicarbonate
- torsemide
Please STOP taking
- simvastatin
- hydralazine
- clonidine oral
- diltiazem
- lasix
Please CHANGE
- your lantus and humalog to reflect sliding scale attached
Please have your PPD read tomorrow on [**2199-12-20**] and have the
results faxed to the number provided to you.
Please monitor your blood sugars closely over the next few days
given that your sugars have been running low.
Please take the rest of your medications as prescribed and
follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 1988**].
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 6086**]
Phone: [**Telephone/Fax (1) 31019**]
Appt: Friday [**2199-12-20**] at 4:30 pm
Department: [**Year (4 digits) **] CENTER
When: MONDAY [**2199-12-23**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 26581**], RN
Location: [**Location (un) 2274**] [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2263**]
Appt: [**12-26**] at 11am
Department: [**Month (only) **] SOCIAL WORK
When: THURSDAY [**2199-12-26**] at 3:00 PM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital Ward Name **] CENTER
When: MONDAY [**2199-12-30**] at 3:40 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
***It is recommended you follow up with a Cardiologist for your
CHF management. The office at [**Location (un) 2274**] [**Location (un) **] is working on an
appt for you and will call you at home with an appt. IF you
dont hear from them by Friday morning, please call the office to
book at [**Telephone/Fax (1) 2258**]
Completed by:[**2199-12-19**]
|
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icd9cm
|
[
[
[]
]
] |
[
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"54.93",
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icd9pcs
|
[
[
[]
]
] |
12849, 12855
|
5248, 9909
|
287, 364
|
12988, 12988
|
3734, 5225
|
14428, 16233
|
2730, 2769
|
10834, 12826
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12876, 12876
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9935, 10811
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13139, 14405
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2784, 3715
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12936, 12967
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240, 249
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392, 2343
|
12895, 12915
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13003, 13115
|
2365, 2638
|
2654, 2714
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,154
| 105,552
|
47939
|
Discharge summary
|
report
|
Admission Date: [**2137-4-1**] Discharge Date: [**2137-4-24**]
Date of Birth: [**2079-8-1**] Sex: M
Service: SURGERY
Allergies:
Neurontin
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Left leg pain and non healing ulcers left foot.
Major Surgical or Invasive Procedure:
[**2137-4-3**]:Serial arteriogram of left lower extremity.
[**2137-4-10**]: Left common femoral endarterectomy, Left femoral to
below-knee popliteal bypass graft using 8-mm Propaten graft,
ring. Left first toe open amputation.
[**2137-4-17**]: Left transmetatarsal amputation.
History of Present Illness:
57 yo male significant PVD, sp left SFA stent and right CFA
pseudoaneurysm presented to clinic with increased left foot pain
on [**2137-4-1**]. Ultrasound at the time showed no flow through the
stent. Left toes and lateral and medial malleolar ulcers all
appeared to have worsened since last visit so patient was
admitted to the hospital for IV antibiotics, wound care and
angiogram.
Past Medical History:
PVD, chronic diastolic CHF with LVEF >55% by TTE [**2-/2134**],
exercise MIBI in [**2-/2134**] with no reversible defects, CKD on
hemodialysis, hypertension, type 2 diabetes, alcohol abuse,
chronic anemia, prior left leg DVT (previously on warfarin),
peripheral neuropathy requiring long-term percocet/oxycodone
use.
Past Surgical History:
[**2131-7-5**]: LLE angio, AK-[**Doctor Last Name **] stenting
[**2131-10-26**]: I&D LLE abscess
[**2132-2-7**]: STSG to LLE ulcers
[**2132-5-19**]: RLE angio showing SFA occlusion
[**2132-5-20**]: R Fem-AK [**Doctor Last Name **] bypass with PTFE
[**2132-5-22**]: R second toe amp
[**2133-6-16**]: Left 2nd and 3rd toe debridements
[**2134-7-20**]: LUE AV graft
[**2136-3-8**]: LLE angio, SFA stent, 2nd, 3rd toe amps
[**2136-3-12**]: amp site debridement, VAC
[**2136-6-1**]: R heel debridement
[**2137-1-30**]: r 4th toe amp
Social History:
Lives at home with girlfriend. Retired. Denies ETOH consumption,
and denies recreational drug use.
Family History:
Diabetes mellitus in both parents.
Physical Exam:
Physical Exam:
Alert and oriented x 3
VSS
Neck: Supple, No jvd, trach midline
Lungs: CTA bilat
Abd: Soft, no m/t/o
Ext: Pulses: Left Femoral palp, DP dop ,PT dop
Right Femoral palp, DP dop ,PT dop
Feet warm, well perfused. TMA Incisions:c/d/i
Wounds: lateral and medial malleolar ulcers clean, scant
drainage. Covered with Acel dressing - this should not be
removed until office follow up.
Pertinent Results:
Other pertinent labs:
[**2137-4-1**] 7:15 pm SWAB Source: Left lower extremity non-healing
wound.
**FINAL REPORT [**2137-4-5**]**
GRAM STAIN (Final [**2137-4-1**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2137-4-5**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. RARE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final [**2137-4-5**]): NO ANAEROBES ISOLATED.
[**2137-4-23**] 05:31AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.8* Hct-28.3*
MCV-93 MCH-28.9 MCHC-31.0 RDW-14.8 Plt Ct-174
[**2137-4-23**] 05:31AM BLOOD Glucose-91 UreaN-28* Creat-6.7* Na-129*
K-4.2 Cl-92* HCO3-26 AnGap-15
[**2137-4-11**] 07:09AM BLOOD ALT-5 AST-25 AlkPhos-53 TotBili-0.3
[**2137-4-23**] 05:31AM BLOOD Calcium-8.7 Phos-5.7* Mg-2.0
[**2137-4-23**] 10:55AM BLOOD Vanco-15.6
Brief Hospital Course:
57 yo male significant PVD, sp left SFA stent and right CFA
pseudoaneurysm presented to clinic for routine followup on
[**2137-4-1**]. Ultrasound at the time showed no flow through the
stent. Left toes and lateral and medial malleolar ulcers all
appeared to have worsened since last visit so patient was
admitted to the hospital for IV antibiotics, wound care and
angiogram. We were unable to cross the left SFA in-stent
occlusion on [**2137-4-3**] so we proceeded to left femoral to posterior
tibial bypass with left first toe amputation on [**2137-4-10**].
Because of ongoing concerns for healing and infecton we needed
to do a left TMA on [**2137-4-17**]. He did well with his multiple
procedures, worked with PT, tolerated a regular diet and
ambulated minimally with assistance.
1.PAD: Mr. [**Known lastname 732**] [**Last Name (Titles) 1834**] angiogram followed by Fem-PT bypass.
He had non healing gangrene of his toes and did ultimately
undergo a left TMA. He followed the bypass/TMA pathway and
progressed nicely during his stay.
2.Arterial Ulcerations: Mr. [**Known lastname 732**] was initialy treated with
santyl and silvadine for his left ankle ulcerations. Dr. [**Last Name (STitle) **]
ultimately placed an ACEL dressing, which will stay in place
until follow up on Thursday, [**5-2**].
3.ESRD: He was continued on his home dyalisis schedule of
tues/thurs/sat, and meds were renally dosed. He received
vancomycin with HD during his hospitalization, and will continue
to recieve it for 2 weeks at rehab.
4.ID: His left toe wound grew MRSA and he was treated with IV
vancomycin via HD protocol. Although he had a TMA, it was
decided that he should continue antibiotics for 2 weeks post
discharge.
5.DM: The patient was maintained on his home sliding scale. He
also monitored his diet as he does at home. His blood sugars
were well controlled.
Medications on Admission:
atorvastatin 80 mg daily, Spiriva 18 mcg daily, humalog SC
sliding scale, aspirin 81 mg daily, albuterol sulfate HFA 90 mcg
INH QID PRN SOB, hydralazine 25 mg Q6H, oxycodone 15 mg Q4-6
hours PRN peripheral neuropathy, amlodipine 5 mg daily,
Lac-Hydrin 12 % Lotion PRN dry skin, calcium acetate 667 mg TID,
cefazolin with HD, carvedilol 12.5'
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
3. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain: pt is on standing oxycodone at home
with pain contract from PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) 101150**] in the post op
period.
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for asthma.
11. INSULIN:HUMALOG
Breakfast Lunch Dinner
Bedtime
0-70 mg/dL Proceed with hypoglycemia protocol
71-159 mg/dL 0 Units 0 Units 0 Units 0
Units
160-179 mg/dL 2 Units 2 Units 2 Units 2
Units
180-199 mg/dL 4 Units 4 Units 4 Units 4
Units
200-219 mg/dL 6 Units 6 Units 6 Units 6
Units
220-239 mg/dL 8 Units 8 Units 8 Units 8
Units
240-259 mg/dL 10 Units 10 Units 10 Units 10
Units
260-279 mg/dL 12 Units 12 Units 12 Units 12
Units
12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
15. vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous per
HD protocol for 2 weeks.
16. Nephrocaps 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left Lower Extremity Ischemia with gangrene
Non healing arterial ulcers
End Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: With Assistance, L heel weight bearing
Discharge Instructions:
You were admitted to the hospital on [**2137-4-1**] with an infection
in your left foot. We were unable to open the blockage in your
artery with balloon angioplasty or stenting so we needed to do a
bypass surgery on your left leg. After we improved the
circulation with surgery, it was felt that the open areas would
still not heal so we did a transmetatarsal amputation.
We started you on a new medication, plavix.
You have a special dressing on your left ankle. DO NOT REMOVE
the dressing. It will be changed by Dr. [**Last Name (STitle) **], only at your
follow up appt.
DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
transmetatarsal amputation(LEFT) you may bear weight on your
heel only for 4-6 weeks. You should keep this amputation site
elevated when ever possible.
You may use the heel of your amputation site for transfer and
pivots. Do not put any pressure on the amputation site.
Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next 14 days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
Avoid pressure to your amputation site.
Followup Instructions:
Department: VASCULAR SURGERY
When: THURSDAY [**2137-5-2**] at 2:15 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2137-4-24**]
|
[
"583.81",
"403.91",
"305.1",
"285.21",
"440.24",
"070.70",
"V58.67",
"250.60",
"357.2",
"707.15",
"V70.7",
"250.40",
"996.74",
"707.13",
"041.12",
"V12.51",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.11",
"39.95",
"00.40",
"39.29",
"84.12",
"38.18",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
9023, 9093
|
4700, 6567
|
315, 594
|
9233, 9233
|
2523, 2523
|
11362, 11722
|
2034, 2071
|
6960, 9000
|
9114, 9212
|
6593, 6937
|
9396, 11196
|
1372, 1901
|
2101, 2504
|
228, 277
|
11208, 11339
|
622, 1009
|
2545, 4677
|
9248, 9372
|
1031, 1349
|
1917, 2018
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,640
| 176,060
|
2234+2235
|
Discharge summary
|
report+report
|
Admission Date: [**2176-6-24**] Discharge Date: [**2176-6-28**]
Date of Birth: [**2124-11-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**6-24**] Coronary artery bypass graft times 5/MAZE/Ligation of left
atrial appendage
History of Present Illness:
Mr. [**Known lastname 11762**] is a 51 year old gentleman with a history of atrial
fibrillation who recently presented to the emergency department
with chest pain. A subsequent cardiac catheterization reveal
multi-vessel coronary artery disease and he was therefore
referred for surgical evaluation.
Past Medical History:
Cardiac History:
Atrial fibrillation. Diagnosed ~[**2166**], initially in paroxysmal
a-fib, occuring with exercise, more recently contstant afib for
~8 years. Rate controlled wiht metoprolol, blood pressure at
baseline 120's / 80's. No other risk factors so not
anticoagulated. Had TEEs in the past to evaluate for clot, most
recently [**2173**], negative for clot and otherwise normal.
Cardiac history negative for hypertension, hyperlipidemia, or
diabetes.
Other Past History:
allergies
actinic keratosis.
Social History:
Mr. [**Known lastname 11762**] is married and has two teenage children. He works
as a sales engineer and exercises by rowing regularly. Other
social history is significant for the absence of current or past
tobacco use. He drinks socially and has no history of alcohol
abuse.
Family History:
The patient's sister has atrial fibrillation, is s/p TIA and on
Coumadin. His mother has osteoporosis, glaucoma, and late onset
coronary artery disease. His father had atrial fibrillation,
coronary artery disease s/p CABG in his 50's, died of testicular
cancer at age 72. His father's 2 siblings also have atrial
fibrillation.
Physical Exam:
At the time of discharge, Mr. [**Known lastname 11762**] was awake, alert, and
oriented. His heart was of regular rate and rhythm with a rub.
His lungs were clear to ausculation bilaterally. His abdomen
was soft, non-tender, and non-distended. His medistinal
incision was clean, dry, and intact. His sternum was stable.
His vein harvest site was clean dry and intact. Trace edema was
noted in his upper extremities.
Pertinent Results:
[**2176-6-28**] 05:40AM BLOOD WBC-8.5 RBC-2.98*# Hgb-9.9*# Hct-26.7*
MCV-89 MCH-33.2* MCHC-37.1* RDW-14.7 Plt Ct-154
[**2176-6-28**] 05:40AM BLOOD Plt Ct-154
[**2176-6-28**] 05:40AM BLOOD PT-21.8* INR(PT)-2.1*
[**2176-6-28**] 05:40AM BLOOD Glucose-104 UreaN-12 Creat-0.8 Na-138
K-4.2 Cl-100 HCO3-32 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 11762**] [**Last Name (Titles) 1834**] a coronary artery bypass grafting times
five (LIMA to LAD, SVG to DIAG1, SVG to DIAG2, SVG to Ramus, SVG
to RCA)/MAZE/Ligation of left atrial appendage on [**2176-6-24**]. This
procedure was performed by Dr. [**Known firstname **] [**Last Name (NamePattern1) 914**]. He tolerated the
procedure well and was transfered in critical but stable
condition to the surgical intensive care unit. On
post-operative day one he was extubated and his vasoactive drips
were weaned. On the following day he was transferred to the
surgical step-down floor. His wires were removed and he was
gently diuresed. He was seen in consultation by the physical
therapy service. His chest tubes were removed. Coumadin was
started. The patient did remain in sinus rhythm throughout the
hospital course. He was discharged in stable condition to home
on POD#4. By the time of discharge, the patient was ambulating
freely, the wound was healing and pain was controlled by oral
analgesics. He was given extensive instructions regarding wound
care, diet restrictions and necessary follow up.
Medications on Admission:
toprol XL 100mg
aspirin 325mg
multivitamin
plavix 75mg
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: dose
may change daily for goal INR [**12-17**], Dr. [**Last Name (STitle) 3306**] to dose.
Disp:*60 Tablet(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease
atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]). Please call for
appointment.
Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiologist) in [**11-15**] weeks.
Please call for appointment.
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3306**] (PCP) in [**11-15**] weeks ([**Telephone/Fax (1) 4775**]). Please
call for appointment.
coumadin f/u: spoke [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5638**] at Dr. [**Last Name (STitle) 3306**]' office-- they
will follow. vna to draw on [**6-29**]- fax to [**Telephone/Fax (1) **], or call
(after 12pm) [**Telephone/Fax (1) 3308**] for [**Name8 (MD) 11582**] MD
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2176-6-28**] Admission Date: [**2176-7-1**] Discharge Date: [**2176-7-5**]
Date of Birth: [**2124-11-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 922**]
Chief Complaint:
Redness of left lower extremity
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51 year old male s/p CABG x5, MAZE, LAA ligation on [**6-24**]
with endovascular vein harvest of the left leg. Patient stated
he started to develop a red streak on left lower leg at
endoscopic vein harvest site that progressively increased during
the day. Denied fever, chills. Patient stated he had one
episode of shakes saturday prior to admission that he related to
anxiety.
Past Medical History:
Cardiac History:
Atrial fibrillation. Diagnosed ~[**2166**], initially in paroxysmal
a-fib, occuring with exercise, more recently contstant afib for
~8 years. Rate controlled wiht metoprolol, blood pressure at
baseline 120's / 80's. No other risk factors so not
anticoagulated. Had TEEs in the past to evaluate for clot, most
recently [**2173**], negative for clot and otherwise normal.
Cardiac history negative for hypertension, hyperlipidemia, or
diabetes.
Other Past History:
allergies
actinic keratosis.
Social History:
Mr. [**Known lastname 11762**] is married and has two teenage children. He works
as a sales engineer and exercises by rowing regularly. Other
social history is significant for the absence of current or past
tobacco use. He drinks socially and has no history of alcohol
abuse.
Family History:
The patient's sister has atrial fibrillation, is s/p TIA and on
Coumadin. His mother has osteoporosis, glaucoma, and late onset
coronary artery disease. His father had atrial fibrillation,
coronary artery disease s/p CABG in his 50's, died of testicular
cancer at age 72. His father's 2 siblings also have atrial
fibrillation.
Physical Exam:
Neuro: alert, oriented, nonfocal
Pulmonary: lungs clear to auscultation bilaterally
Cardiac: Irregular rhythm. No murmurs or rubs appreciated.
Sternum stable with no erythema
Abdomen: soft and nontender, positive bowel sounds
Extremities: warm without edema. Left lower extremity cellulitis
improving.
Left leg incisions clean and dry.
Pertinent Results:
[**2176-7-1**] 07:05PM BLOOD WBC-11.1* RBC-3.29* Hgb-10.6* Hct-29.9*
MCV-91 MCH-32.3* MCHC-35.5* RDW-15.4 Plt Ct-377#
[**2176-7-1**] 07:05PM BLOOD PT-31.8* PTT-34.4 INR(PT)-3.3*
[**2176-7-1**] 07:05PM BLOOD Glucose-104 UreaN-11 Creat-0.9 Na-133
K-4.6 Cl-95* HCO3-29 AnGap-14
[**2176-7-1**] 07:05PM BLOOD ALT-125* AST-107* LD(LDH)-387*
AlkPhos-170* Amylase-144* TotBili-0.8
[**2176-7-1**] 07:05PM BLOOD Lipase-113*
[**2176-7-1**] 07:05PM BLOOD CRP-61.4*
[**2176-7-1**] 06:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2176-7-1**] Chest x-ray: 1. Interval decrease in bilateral apical
pneumothoraces. 2. Small bilateral pleural effusions with
associated basilar atelectasis
Brief Hospital Course:
Mr. [**Known lastname 11762**] was admitted for intravenous antibiotics for left
lower extremity cellulitis. He was started on intravenous
Unasyn. Shortly after admission, patient was noted to be in and
out of atrial fibrillation/flutter with a ventricular response
of up to 140 BPM. Dr [**Last Name (STitle) **] is the patients cardiologist and
decided to treat with IV Lopressor for rate control, with
specific request for no amiodarone. His PO Lopressor was up
titrated to 75 mg PO BID with better control of his ventricular
response.
On hospital day 3 he was put back on his home dose of Toprol XL
100 mg po daily. His INR was elevated on admission to 3.3. It
was held for several days, being given 0.5 mg PO on HD3 when he
had an INR of 2.6.
The left lower extremity cellulitis showed significant
improvement on HD3 and Dr [**Last Name (STitle) 914**] felt patient would do well
with one more day of intravenous Unasyn and then discharge home
on Keflex PO for 7-10 days.
Also of note, patient's LFT's were found to be elevated so his
Lipitor and Tylenol were discontinued. After discontinuation,
LFT's trended towards normal. An ultrasound of his gallbladder
revealed sludge but no acute cholecystitis.
A loop monitor was placed by Dr.[**Name (NI) 1565**] service to monitor
his heart rate. A GI follow-up was recommended to his PCP for
further following of his elevated liver enzymes. Dr. [**Last Name (STitle) 3306**]
will manage his coumadin for a goal INR of 2.0-2.5. Her office
was notified on day of discharge and VNA will draw a PT/INR on
Saturday and Monday and then as instructed by Dr. [**Last Name (STitle) 3306**].
The discharged dose was reduced to 2mg.
Medications on Admission:
1. Toprol XL 100 MG PO daily
2. ASA 325 MG PO daily
3. MVI PO daily
4. Coumadin 4 MG PO daily
5. Lipitor 20 MG PO daily
6. Plavix 75 MG PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*1*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 1 months: For one month after surgery.
Disp:*90 Tablet(s)* Refills:*0*
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days: For left lower extremity cellulitis.
Disp:*40 Capsule(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): Pt
noted history of GI upset with sustained NSAID use.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Take 2mg daily or as directed by Dr [**Last Name (STitle) 3306**]. INR to be drawn
over weekend and then [**7-8**]. Goal INR 2.0-2.5.
Disp:*60 Tablet(s)* Refills:*0*
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left lower extremity cellulitis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Coumadin for atrial fibrillation with Goal INR 2.0-2.5. Dr.
[**Last Name (STitle) 3306**] to manage coumadin as an outpatient. Discharge dose
will be 2mg daily. VNA may draw PT/INR over weekend.
8) Please follow-up with a GI specialist through Dr. [**Last Name (STitle) 3306**]
regarding your elevated LFT's and gall bladder sludge. Dr.
[**Last Name (STitle) **] has spoken to your PCP regarding this.
9) You will be discharged home on a loop moitor followed by Dr.
[**Last Name (STitle) **] for atrial flutter.
10) 10 days of keflex for wound infection
11) Call with any questions or concerns.
Followup Instructions:
- Dr [**Last Name (STitle) 914**] in [**11-15**] weeks.
- Keep other appointments as directed by previous discharge
instructions.
- Take Coumadin 2mg daily or as directed by Dr [**Last Name (STitle) 3306**]. INR
to be drawn on Monday [**7-8**]. Plan confirmed with Dr
[**Last Name (STitle) 11844**]. Results may be faxed to [**Telephone/Fax (1) **], or call (after
- Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2176-9-3**] 1:40 or as instructed.
You will go home on a loop monitor which will be followed by Dr.
[**Last Name (STitle) **].
Completed by:[**2176-7-5**]
|
[
"414.01",
"746.9",
"410.82",
"998.59",
"276.4",
"682.6",
"E849.7",
"790.92",
"E878.2",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"37.27",
"37.33",
"36.14",
"39.61",
"38.93",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
13329, 13387
|
9909, 11583
|
7184, 7191
|
13463, 13470
|
9145, 9886
|
14770, 15429
|
8444, 8774
|
11778, 13306
|
13408, 13442
|
11609, 11755
|
13494, 14747
|
8789, 9126
|
7113, 7146
|
7219, 7599
|
7621, 8132
|
8148, 8428
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,487
| 165,833
|
54638
|
Discharge summary
|
report
|
Admission Date: [**2162-6-7**] Discharge Date: [**2162-6-12**]
Date of Birth: [**2094-8-8**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Coffee-ground Emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 67yo F with history of alcohol abuse who prseented
to OSH with coffee-ground emesis for 1 week and having loose
BMs, 2-3 times per day, also with some black discoloration
transferred to [**Hospital1 18**] for further management.
Per OSH records, the patient had coffee-ground emesis as well as
diarrhea reportedly black in color. The patient was admitted
because of confusion as well as jaundice. She was admitted to
OSH with Upper GI bleed. The patient underwent EGD and initially
was started on Protonix and Octreotide gtts. EGD showed evidence
of esophagitis, but there was no evidence of varices. Patient
received 1 unit of pRBCs and 2 units of FFP. The patient also
was intubated for AMS. Head CT was negative. Chest CT was
notable for RLL opacity and abdominal CT was significant for
asicites as well as a possible colitis.
Patient was also noted to be in [**Last Name (un) **] with serum Cr of 4.9. Renal
was consulted as the OSH who felt that her [**Last Name (un) **] was secondary to
pre-renal causes. Home diuretics were held and she was bolused
with IVFs. The patient's serum creatinine improved to 3.9 on day
of discharge reportedly with diuresis.
She was noted to be hypotensive and was started on pressors. The
patient was started on vassopressin as well as levophed. The
patient was started on antibiotics with vancomycin, cefepime,
and falgyl.
During her OSH hospitalization, the patient was noted to be more
difficult to ventilate requiring increaing FiO2 as well as
increasing PEEP. She underwent bronchoscopy at the OSH that did
show yeast. She was started on Diflucan for yeast.
On arrival to the MICU, the patient is intubated and sedated
spontaneously moving all 4 extremities, but not following
commands.
Review of systems: Unable to obtain secondary to mental status.
Past Medical History:
--h/o esophageal varices
--Gout
--LE edema
--s/p surgery for ankle fracture
Social History:
(per OSH records) Smoked all her life. Drinking 5 glasses of
wine daily. Denies illicit drug use.
Family History:
NC
Physical Exam:
Discharge physical exam: Expired.
Pertinent Results:
Admission labs:
[**2162-6-7**] 05:41PM BLOOD WBC-11.5* RBC-2.65* Hgb-10.0* Hct-30.9*
MCV-117* MCH-37.9* MCHC-32.5 RDW-20.3* Plt Ct-66*
[**2162-6-11**] 03:33AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Burr-2+
[**2162-6-7**] 05:41PM BLOOD PT-20.1* PTT-34.8 INR(PT)-1.9*
[**2162-6-7**] 05:41PM BLOOD Glucose-131* UreaN-83* Creat-4.3* Na-142
K-3.6 Cl-110* HCO3-21* AnGap-15
[**2162-6-7**] 05:41PM BLOOD ALT-35 AST-88* LD(LDH)-287* AlkPhos-65
TotBili-5.9*
[**2162-6-7**] 05:41PM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.8 Mg-1.8
[**2162-6-7**] 06:24PM BLOOD Lactate-2.1*
Microbiology:
[**2162-6-8**] 3:02 am URINE Source: Catheter.
**FINAL REPORT [**2162-6-9**]**
URINE CULTURE (Final [**2162-6-9**]):
PROBABLE ENTEROCOCCUS. ~4000/ML.
[**2162-6-8**] 11:40 am BLOOD CULTURE times 2
**FINAL REPORT [**2162-6-14**]**
Blood Culture, Routine (Final [**2162-6-14**]): NO GROWTH.
[**2162-6-8**] 3:35 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT [**2162-6-14**]**
GRAM STAIN (Final [**2162-6-8**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2162-6-11**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2162-6-14**]): NO GROWTH.
Imaging:
Renal Ultrasound:
FINDINGS: The left kidney measures 8.0 cm. A 6 mm
nonobstructing stone is
seen in the lower pole of the left kidney. The right kidney
measures 8.9 cm.
No stones or masses are identified in the right kidney. There
is no
hydronephrosis in either kidney. Normal color flow is
visualized throughout
the right and left kidneys. Normal color flow and spectral
Doppler waveforms
are identified in the right and left main renal vein and main
renal artery.
The peak systolic velocity in the left main renal artery is 41.5
cm/sec, and
in the right main renal artery is 56.1 cm/sec. Arterial
waveforms bilaterally
show sharp systolic upstrokes with antegrade flow throughout
diastole.
A moderate amount of ascites is seen throughout the abdomen.
The urinary
bladder is collapsed about a Foley catheter.
IMPRESSION:
1. Nonobstructing left lower pole renal stone. No evidence of
renal masses
or hydronephrosis.
2. Patent main renal artery and vein bilaterally, without
evidence of renal
vascular thrombosis.
3. Ascites.
Head CT
FINDINGS: There is no acute intracranial hemorrhage, edema,
mass effect or
major vascular territorial infarct. Prominent ventricles and
sulci are
compatible with global atrophy, slightly more than expected for
the patient's
age. The basal cisterns are patent. There is no shift of
normally midline
structures. [**Doctor Last Name **]-white matter differentiation is preserved. No
osseous
abnormality is identified. The visualized paranasal sinuses and
mastoid air
cells are clear.
IMPRESSION:
1. No acute intracranial process.
2. Global atrophy, slightly more than expected for patient's
age.
Brief Hospital Course:
Patient is a 67yo F with PMHx of EtOH abuse who presented with
coffee-ground emesis to OSH found to have esophagitis on EGD
with no evidence of varices, intubated for altered mental status
requiring intubatio, and hypotension (unclear if this is the
patient's baseline) requiring pressor support, OSH course c/b
[**Last Name (un) **] thought to be [**1-7**] volume depletion who is transferred for
further management who was transitioned to comfort measures only
in light poor prognosis in light of liver disease.
# Cirrhosis: Likely related to EtOH abuse. Patient with evidence
of synthetic dysfunction with elevated INR, thrombocytopenia.
Recent EGD with no evidence of varices. Evidence of mild
ascities that was not tapped at the OSH. Periotenal fluid was
collected here for culture as part of work-up, which returned
negative. Hepatology was consulted as well, who felt that the
patient had a very poor prognosis. In light of her poor
prognosis, the patient's family decided not to pursue further
work-up and she was transitioned to comfort measures only.
# [**Last Name (un) **]: Patient with serum creatinine of 4.3; upon dischage from
OSH, the patient had a serum creatinine 3.9. Renal at OSH
attributed the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] to hypovolemia [**1-7**] diuretics and
poor PO intake. Etiologies of the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] include
hypovolemia versus HRS in light of liver disease. Renal was
consulted in light of the patient's elevated serum creatinine.
The differential included HRS versus ATN. She was challenged
with albumin with no response in the paitent's urine output.
Initially HD was going to be pursued, but with a transition in
goals of care after discussion with the patient's family
regarding her poor progrnosis, HD line was not placed.
# Respiratory failure: Patient intubated at the OSH primarily
for AMS. Since being at the OSH, the patient has been more
difficult to oxygenate, requiring increaseing FiO2 and PEEP,
which is concerning for the development of ARDS; saturations
have improved with vent adjustments at OSH. Patient underwent
bronchoscopy at the OSH which showed [**Female First Name (un) **]. Possibly
etiologies of ARDS in this patient include PNA versus TRALI (s/p
2 units pRBCs at OSH). Patient did not have ARDS. She was able
to be extubated.
# Hypotension: Patient arrived to MICU on vassopressin and
norepinephrine. Patient has since been weaned off vassopressin.
Nadolol and aldactone were held. Possible that the patient has
low-normal BPs in light of cirrhosis. Patient is not tachycardic
and there is no obvious source of infection localized. She was
weaned from lveophed. The patient was also started on midodrine.
# Altered mental status: Patient awake, but not following
commands. Spontaneously moving all 4 extremities. Patient
currently off sedation. Possibly secondary to hepatic
encephalopathy in light of alcohol abuse and evidence of
cirrhosis on OSH RUQ U/S. Head CT as OSH negative. She was
restarted on lactulose. She underwent head CT for dilated pupil
on the left when compared with the right which was negative.
# History of alcohol abuse: Patient with AST:ALT ratio 2:1,
suggestive of alcohol hepatitis. Patient's OSH RUQ U/S showing
evidence of cirrhosis.
# GI Bleed: Patient with evidence of esophagitis at OSH on EGD.
Patient's HCT acutely fell along with platelet count and guiaic
positive stools. She was continued on pantorazole 40mg IV BID in
light of her history of eosphagitis.
# Thrombocytopenia: Platelet count 60K at OSH prior to transfer.
Likely a component of decreased hepatic synthetic function in
light of elevated INR and low platelets as well as component of
Vitamin B12 deficiency. Platelets were trended and noted to be
decreasing in the setting of GI bleed.
# history of diabetes: Continued insulin sliding scale.
# history of gout: Patient on allopurinol as an outpatient,
which was held in the context of [**Last Name (un) **].
Medications on Admission:
Medications HOME:
--Lasix 20mg daily
--Folic acid 1mg daily
--nadolol 20mg daily
--Allopurinol 300mg daily
--Aldactone 25mg daily
--Thiamine 100mg daily
.
Medications on TRANSFER:
--Hydrocortisone 25mg [**Hospital1 **]
--Thiamine 100mg daily
--Artificial tears PRN
--Ceftaroline every 12 hours
--MVI daily
--Zofran 4mg q6hours PRN
--Norepinephrine IV
--Pitressin GTT
--Chlorexidine 0.12% [**Hospital1 **]
--Furosemide 40mg daily
--Levaquin 500mg IC
--Magnesium Aluminum 30mg QID PRN
--Bisacodyl 10mg [**Hospital1 **]
--Duoneb 1 Neb q4hours PRN
--Folic acid 1mg daily
--Humalog Sliding Scale
--Diflucan 100mg QOD
--Linezolid 600mg
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"276.8",
"274.9",
"789.59",
"276.52",
"427.31",
"303.91",
"790.92",
"571.2",
"578.0",
"V49.86",
"276.0",
"518.0",
"305.1",
"572.2",
"584.9",
"285.9",
"287.5",
"112.84",
"V49.87",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10247, 10256
|
5516, 8287
|
330, 336
|
10307, 10316
|
2482, 2482
|
10372, 10518
|
2409, 2413
|
10215, 10224
|
10277, 10286
|
9561, 9716
|
10340, 10349
|
2428, 2428
|
2132, 2178
|
270, 292
|
364, 2113
|
2499, 5493
|
8302, 9535
|
9741, 10192
|
2200, 2278
|
2294, 2393
|
2453, 2463
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,254
| 142,640
|
20557
|
Discharge summary
|
report
|
Admission Date: [**2191-12-12**] Discharge Date: [**2192-1-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1631**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
Swan
History of Present Illness:
86 year old male with chief complaint of passage of melanotic
stool this morning. Patient is s/p right lung decortication in
[**Month (only) **], complicated by C. diff and empyema and
re-hospitalization. Hospitalized again [**11-29**] for SOB, no
specific cause found. Now at home with daughter as caregiver.
She called to report thick, tarry stool this morning and hypoxia
to the 70's (has been on chronic O2 since the surgery in
[**Month (only) **]). Daughter also called on [**2191-12-9**] with single episode of
BRBPR but PCP felt that this was [**1-5**] to recent C-Diff colitis.
Episode was tarry.
.
In ED, noted SBP 95, with HR 140's. Received 2 L IVF--->hypoxic
with CXR findings of vol overload. Receieved 2 Units B RBC's.
HCT on arrival was 23 and INR 10 (last INR last week was 2.0)
.
.
Currently, "feels OK". states that breathing is a his baseline.
Denies any CP/new PNA, baseline LE edema. No new Coumdain
adjustments. Has not been on any recent antibiotics or ofther
meds.
Past Medical History:
1. Coronary artery disease.
2. Peripheral vascular disease.
3. History of atrial fibrillation/flutter, on anticoagulation.
4. Sensorineural hearing loss.
5. Mild cognitive impairment.
6. Osteoporosis.
7. Peptic ulcer disease. (no EGD in our Records)
8. Status post CABG x3 in [**2189**].
9. Status post right carotid endarterectomy in [**2189**].
10. Total decortication of right lung on [**2191-10-17**] for
recurrent Right pleura effusion. He was discharged from this
operation on [**2191-10-26**], and readmitted on [**10-28**]
with an empyema--->anterior loculated hydropneumothorax, which
eventually was positive for MRSA. All biopsy and cytology neg.
for malignancy.
Social History:
The patient is a retired accountant. He is a widower; his wife
died a couple months ago. Daughet is HCP (lives with him)
Family History:
non-contrib
Physical Exam:
T:96.9 P:AF with RVR 99-141 on tele R:18-30 BP:119/90 SaO2:99%
on NRB
General: Awake, alert, oriented x3; speaking [**2-4**] words/breath.
no acc. muscles of resp..
HEENT: NC/AT, PERRLA, EOMI, no scleral icterus noted, MMdry,
Neck: supple, Flat Neck veins. no carotid bruits appreciated
Pulmonary: Course rhonchi R/L, with decrease BS at right and
left base. + crackles.
Cardiac: [**Last Name (un) **] [**Last Name (un) **], tacky in 100's, hyperdynamic without MRG.
Right throocotomy scar well-healed. Sternotomy scar
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Guaciac +
Extremities: No cyanosis, no clubbing. +2 P edema to mid shin
(baseline per patient and duaghter). 1+ DP and PT pulses b/l.
Skin: no rashes or lesions noted.
Pertinent Results:
ECHO [**2192-12-1**]: Conclusions:
1. The left atrium is mildly dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity size and systolic function (LVEF>55%). Regional
left ventricular wall motion
is normal. 3. The right ventricular cavity is moderately
dilated. Right ventricular
systolic function appears depressed. 4. The aortic valve
leaflets (3) are mildly thickened. Mild to moderate ([**12-5**]+)
aortic regurgitation is seen. 5. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-5**]+)
mitral regurgitation is seen.6. Moderate to severe [3+]
tricuspid regurgitation is seen. 7. Compared with the findings
of the prior study of [**2191-11-1**], LV function has
improved.
.
C-Scope: [**2191-6-3**]: Diverticulosis of the sigmoid colon
Otherwise normal colonoscopy to cecum .
.
CXR: [**2191-12-28**]:
INDICATION: History CAD, CHF, possibly new aspiration pneumonia,
Swan placement.
Comparison is made to the chest x-ray obtained one day prior.
FINDINGS: There is again present a Swan-Ganz catheter with the
tip terminating in the distal left pulmonary artery. An
endotracheal tube and an NG tube remains in stable position.
Median sternotomy wires are noted. The appearance of the lungs
are not significantly changed with persistent bilateral patchy
opacities predominantly in the mid and lower lung zones. There
are also persistent small bilateral pleural effusions.
.
CXR [**2192-1-6**]: HISTORY: Aspiration pneumonia status post
extubation.
COMPARISON: [**2192-1-4**].
AP CHEST RADIOGRAPH: The patient has been extubated in the
interval. The right IJ line remains in unchanged position. The
NG tube has been removed.
The degree of pulmonary edema is unchanged. There is patchy
atelectasis at the bases, unchanged as well.
IMPRESSION: Patchy bibasilar atelectasis unchanged. Unchanged
pulmonary edema.
Brief Hospital Course:
86 year old male with multiple medical problems, on coumadin for
atrial fibrillation, who initially presented with melanotic
stools in setting of supratherapudic INR. Patient suffered
repiratory failure from fluid overlaod and was transferred to
the ICU, was extubated and re-intubated, suffered aspiration
event, and ultimately made CMO. Patient expired 1 day after
being transferred to the floor. The following issues were
addressed during his hospital stay:
* Respiratory failure: Intubated for hypercarbic resp failure
[**1-5**] volume overload. Peak pressures elevated on vent so nebs
added to decrease airway resistance. PIPs and plat still
elevated likely [**1-5**] volume overload but improved following
diuresis. He was extubated on [**12-23**] but as above, reintubated on
[**12-26**] due to an episode of pulmonary edema/aspiration/mucous
plug/VAP. During his second course of intubation, he was treated
for his pneumonia and his secretions improved. He was also
restarted on his lasix drip to maximize his lung mechanics for
another try at extubation. At a family meeting following his
second intubation, it was decided that there would be no trach
and no reintubation once he was extubated. Successfully
extubated [**1-4**]. Had aspiration event, per family meeting,
decision for Comfort Measures Only, patient expired on on
morphine gtt due to respiratory distress.
.
* Pneumonia: During his first course of intubation, pt grew out
Klebsiella and MRSA in his sputum. However, given the lack of
fever, infiltrate or leukocytosis, he was not started on
antibiotics. After extubation, pt had worsening secretions that
he could not control. Once he was reintubated, his wbc rose and
he was noted to have a fever with possible new RML infiltrate.
he was therefore started on Vanc/Zosyn for a 10 day course of
aspiration vs vent-associated pneumonia. Given change in goals
of care, no further antibiotics were administered. Morphine gtt
administered for comfort care.
.
* Hypotension: Initially, hypotension, HR and urine output
responsive to fluids however became less so as MICU course
progressed. No evidence of sepsis. Swan on [**12-14**] shows elevated
CVP and wedge with low CO and elevated SVR indicating poor
forward flow [**1-5**] afib with RVR. [**Last Name (un) **] stim normal response.
Started on amio drip on [**12-14**] with no response in HR (still
~120s) and MAPs stable in 70s. However, the following day, MAPs
dropped into the 50s-60s so pt was started on Levophed. Echo on
[**12-15**] showed a new decreased EF to 35% (>60% on [**2191-12-2**]) with
new wall motion abnormalities suggesting NSTEMI. Over the next
few days, heart rate came down with improved pressure on
levophed allowing the initiation of a lasix drip. When pt was
reintubated on [**12-26**], his BP dropped again suggesting that his
hypotension is related to positive pressure and sedation. Swan
numbers did not indicate any signs of sepsis. Lasix drip was
started on and off for diuresis, was off all drips given change
in care.
.
* CHF: As above, pt with new depressed EF on recent echo.
Multiple valvular abnormalities including mod MR, mod AR, severe
TR, severe PR. Swan on [**12-14**] showed elevated CVP and wedge
indicating volume overload. Started on Lasix gtt on [**12-15**] with no
increase in urine output. Then started on nitro gtt for
additional afterload reduction but this was stopped after
dramatic drop in BP. Pt was then started on Dobutamine briefly
but this was again stopped after drop in BP. Pt was started on
Levophed with improvement in MAPs so Lasix gtt was again
resumed. Pt started diuresing to low dose Lasix gtt. As BP
improved, Levpophed was titrated off and pt was restarted on his
ACE-I and BB for further afterload reduction. Pt continued to
diurese with goal of one liter negative per day. He was
successfully extubated on [**12-23**]. On a few occasions, pt was noted
to have elevated BP, HR and CVP indicating flash pulmonary
edema. On [**12-26**], pt had another episode of pulm edema that was
not responsive to nitro patch, morphine and lasix x 2. he was
placed on BiPAP but was tachypneic to 40-50s with minute
ventilation of 22-23. He was then reintubated. Again, he was
started on levophed for a drop in his BP but also on a lasix gtt
for diuresis. As above, lasix drip and levophed was started on
and off according to his pressure. His became alkalotic with
further diuresis with difficultly in weaning and was started on
diamox on [**1-2**]. Given change in care status, no further diuresis
was pursued while CMO.
.
* Afib with RVR: Pt went into a fib with RVR during acute event
of GI bleed with resp distress. Of note, pt has failed DCCV in
the past. Starting amio gtt on [**12-14**] and converted to po amio
on [**12-16**]. Rate was better controlled in 100s. Cardiac meds were
held as patient CMO.
.
* CAD: Pt with troponin bump to 0.56 in setting of acute event
of GI bleed and afib/RVR with hypotension, hence likely demand
ischemia. Now with new wall motion abnormalities. [**Name (NI) 54984**], pt
was weaned off pressors and restarted on his ACE-I and BB. He
was continued on ASA. troponin trended down and repeat echo
showed normalization of EF. It was thought that pt was failing
to wean [**1-5**] his heart disease (leading to ischemic MR which led
to flash pulm edema during an SBT). The swan was replaced and CO
was determined prior to and following an SBT. The pt tolerated
the SBT so there was no evidence that ischemia was preventing
his extubation. he was extubated. When he was reintubated, a
dobutamine stress echo was done at the bedside and showed no
signs of ischemia. Given change in care status, no further
cardiac w/u was pursued.
.
* GIB: likely upper GIB (has prior H/O of PUD although no EGP's
in our records.) Divertic + on [**6-6**] C-SCope. INR reversed with
FFP and vitamin K, now normalized. Hct stable s/p 5U PRBCs
total. EGD on [**12-22**] showed no signs of gastritis or ulcers. hct
slowly trended down during ICU stay possible due to slow lower
GI bleed (hemorrhoids?). He was transfused for a hct<25 due to
his recent NSTEMI. Above issues then became focus of care.
.
* UTI: When UA checked for sediment, noted to have 21-50 WBC
with mod bacteria. Sent for cx which returned VRE, [**Last Name (un) 36**] to
ampicillin. Completed 7-day course.
.
* Decreased urine output: Urine lytes show Na of 10 indicating
pre-renal likely [**1-5**] poor forward flow. Creatinine slowly
increased over hosp stay likely [**1-5**] ATN (in setting of
hypotension) and poor forward flow. Urine output improved with
lasix gtt and Levophed for better BP. Cr trended down.
.
*Access: quad-lumen ([**12-14**])
.
*Code Status: Patient's code status changed from DNR/DNI to CMO
given changes in health status as per above. Patient expired on
[**2192-1-8**] [**1-5**] respiratory distress.
Medications on Admission:
1. Aspirin 81 mg po QD
2. Warfarin 2 mg PO HS
3. Calcium Carbonate 500 mg PO BID
4. Cholecalciferol (Vitamin D3) 400 unit Tablet po QD
5. Tamsulosin 0.4 mg qHS
6. Atorvastatin 40 mg PO DAILY
7. Cilostazol 50 mg PO BID
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
9. Lisinopril 10 mg PO QD
10. Lopressor 50 mg PO BID
Discharge Medications:
NA, Patient expired
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. respiratory failure
2. atrial fibrillation
3. hypotension
4. congestive heart failure
5. gastrointestinal bleed
6. pneumonia
7. acute renal failure
8. depression
Discharge Condition:
expired
Discharge Instructions:
NA
Followup Instructions:
NA
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1636**]
Completed by:[**2192-2-14**]
|
[
"733.00",
"482.41",
"E934.2",
"707.03",
"211.1",
"276.3",
"389.10",
"578.1",
"V45.81",
"458.9",
"799.02",
"584.5",
"427.31",
"518.81",
"785.51",
"414.00",
"428.0",
"E849.8",
"410.71",
"599.0",
"562.00",
"041.04",
"482.0",
"280.9",
"428.30",
"401.9",
"424.2",
"440.20",
"275.41",
"V09.0",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"99.07",
"38.91",
"93.90",
"88.72",
"45.13",
"38.93",
"99.04",
"89.64",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
12130, 12145
|
4854, 11701
|
269, 275
|
12353, 12362
|
2963, 4831
|
12413, 12569
|
2146, 2159
|
12085, 12107
|
12166, 12332
|
11727, 12062
|
12386, 12390
|
2174, 2944
|
223, 231
|
303, 1294
|
1316, 1991
|
2007, 2130
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,174
| 175,429
|
19520
|
Discharge summary
|
report
|
Admission Date: [**2189-9-22**] Discharge Date: [**2189-9-28**]
Date of Birth: [**2136-2-23**] Sex: M
Service: SURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Fall from standing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 yo male [**2136**]0 days ago presents with 2 days of abdominal
pain. CT revealed ruptured spleen w/ HCT 45-->39 and FSG 400's.
No N/V/CP/SOB
Past Medical History:
NIDDM
[**First Name9 (NamePattern2) 30065**] [**Location (un) **]
HTN
Social History:
lives at home
lawyer
Family History:
n/c
Physical Exam:
AOx3, NAD
RRR CTA bilat
SOFT, NT/ND, nabs, no external signs of trauma
Ext: WWP, No C/C/E
Pertinent Results:
[**2189-9-25**] 06:55AM BLOOD WBC-12.3* RBC-3.06* Hgb-9.0* Hct-27.0*
MCV-88 MCH-29.5 MCHC-33.5 RDW-13.3 Plt Ct-253
[**2189-9-25**] 12:30AM BLOOD Hct-27.0*
[**2189-9-24**] 12:01PM BLOOD Hct-29.2*
[**2189-9-23**] 09:57PM BLOOD Hct-28.7*
[**2189-9-23**] 10:55AM BLOOD WBC-15.0* RBC-3.68* Hgb-10.4* Hct-31.8*
MCV-87 MCH-28.4 MCHC-32.8 RDW-13.5 Plt Ct-231
[**2189-9-23**] 02:34AM BLOOD WBC-19.5* RBC-3.93* Hgb-11.3* Hct-34.0*
MCV-87 MCH-28.8 MCHC-33.2 RDW-13.7 Plt Ct-261
[**2189-9-22**] 08:40PM BLOOD WBC-15.3* RBC-3.98* Hgb-11.8*# Hct-34.7*#
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.5 Plt Ct-239
[**2189-9-22**] 09:45AM BLOOD WBC-22.2* RBC-5.12 Hgb-15.3 Hct-45.6
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.4 Plt Ct-310
[**2189-9-23**] 10:55AM BLOOD Neuts-86.6* Lymphs-10.2* Monos-3.0
Eos-0.1 Baso-0.1
[**2189-9-22**] 08:40PM BLOOD Neuts-87.8* Lymphs-9.1* Monos-2.9 Eos-0.1
Baso-0.2
[**2189-9-22**] 09:45AM BLOOD Neuts-89.7* Bands-0 Lymphs-6.9* Monos-2.4
Eos-0.3 Baso-0.6
[**2189-9-25**] 06:55AM BLOOD Plt Ct-253
[**2189-9-25**] 06:55AM BLOOD PT-14.3* PTT-25.8 INR(PT)-1.4
[**2189-9-24**] 03:22AM BLOOD Plt Ct-258
[**2189-9-22**] 09:45AM BLOOD Plt Ct-310
[**2189-9-25**] 06:55AM BLOOD Glucose-130* UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-101 HCO3-25 AnGap-14
[**2189-9-22**] 09:45AM BLOOD Glucose-442* UreaN-16 Creat-1.1 Na-136
K-5.0 Cl-93* HCO3-25 AnGap-23*
[**2189-9-25**] 06:55AM BLOOD Glucose-130* UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-101 HCO3-25 AnGap-14
[**2189-9-22**] 06:47PM BLOOD ALT-15 AST-17 AlkPhos-80 Amylase-19
TotBili-0.6
[**2189-9-22**] 09:45AM BLOOD ALT-19 AST-20 AlkPhos-114 Amylase-27
TotBili-0.9
[**2189-9-22**] 06:47PM BLOOD Lipase-15
[**2189-9-22**] 09:45AM BLOOD Lipase-19
[**2189-9-25**] 06:55AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.9
[**2189-9-22**] 09:45AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.0
[**2189-9-23**] 02:34AM BLOOD HCG-<5
[**2189-9-23**] 02:34AM BLOOD CEA-1.1 AFP-<1.0
IMPRESSION:
1. Splenomegaly with splenic laceration/rupture. Blood is seen
tracking along the intra-abdominal fascia, including
perisplenic, perihepatic, and pericolonic gutters
2. 4.1 x 1.8 cm poorly defined soft tissue density mass in the
area of the splenic hilum, which appears to arise from the
pancreatic tail and is largely indistinguishable from the
surrounding blood. Repeat dedicated CTA is recommended for
complete evaluation.
3. Splenic vein thrombosis with additional thrombosis of several
prominent collaterals.
4. Splenic hemangioma.
5. Diverticulosis.
6. Low-density lesions within the liver are incompletely
characterized. These most likely represent simple cysts.
7. Bilateral renal cysts.
Brief Hospital Course:
Admitted to TSICU for serial hematocrit. After initial drop,
HCT stabilized at 27 for greater than 24 hours. Patient
transferred to general [**Hospital1 **] in stable condition. Noted
continuous improvement of LUQ pain and tenderness. Intermittent
fevers and mildly elevated WBC (19-->15-->13.9-->12.3) treated
empirically with vancomycin, ceftriaxone, and flagyl.
Infectious disease followed and recommended current therapy as
well as outpatient regimen of levaquin/flagyl x 7-10 days.
Patient was evaluated by the Gold Surgery team and deamed stable
for discharge with follow up in 1 week.
Medications on Admission:
Univasc
Metformin
Amaryl
Discharge Medications:
1. Resume home medications
2. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*45 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Several peripheral segmental areas of portal venous occlusion
and thrombosis
2. Splenic rupture
3. Splenic hematoma
4. Vascular thrombosis
Discharge Condition:
Stable
Good
Discharge Instructions:
Avoid trauma to your abdomen and remain within 30 minutes of a
hospital at all times. Return to the emergency department for
continued fevers, worsening abdominal pain, chest pain,
difficulty breathing, nausea or vomiting or other significant
concerns.
Followup Instructions:
1. Gold Surgery, Dr. [**Last Name (STitle) 468**] in 1 week. [**Telephone/Fax (1) 6449**]
2. Trauma Clinic in 1 week ([**Telephone/Fax (1) 6449**]
|
[
"518.0",
"902.33",
"250.00",
"401.9",
"780.6",
"E888.9",
"865.03",
"902.34"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4484, 4490
|
3353, 3951
|
290, 297
|
4676, 4690
|
749, 3330
|
4992, 5144
|
619, 624
|
4026, 4461
|
4511, 4655
|
3977, 4003
|
4714, 4969
|
639, 730
|
232, 252
|
325, 472
|
494, 565
|
581, 603
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,298
| 194,189
|
40408
|
Discharge summary
|
report
|
Admission Date: [**2178-4-24**] Discharge Date: [**2178-5-6**]
Date of Birth: [**2119-8-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base / Codeine / IV Dye, Iodine Containing Contrast
Media
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2178-4-24**]
1. Aortic valve replacement with a 19-mm St. [**Male First Name (un) 923**] Regent
mechanical valve.
2. Root enlargement with pericardial patch closure.
History of Present Illness:
58 year old female with hypertension,
type 2 diabetes, and obesity, who developed acute shortness of
breath at rest in [**Month (only) 956**] and was diagnosed and treated for
PNA.
Since that time she has continued with significant dyspnea on
exertion. Further work up included an echo which revealed severe
AS. With regards to symptoms she reports significant shortness
of
breath with walking as little as 5 to 6 steps. She denies chest
pain but reports this is often accompanied by chest "soreness"
and lung "ache". This resolves immediately with rest. She denies
any lightheadedness or dizziness. She denies any presyncope or
syncope. She reports mild bilateral ankle edema, left greater
than right that is usually resolved by morning after her feet
are
elevated. She does report rare occasional palpitations with
exertion but states these are not bothersome. She was referred
for a cardiac catheterization for further evaluation. She was
found to have no coronary artery disease and is now being
referred to cardiac surgery for an aortic valve replacment.
Past Medical History:
Aortic Stenosis
Pneumonia
Hypertension
Type 2 Diabetis Mellitus
Past Surgical History:
s/p tonsillectomy
s/p Cholecystectomy
Social History:
Lives with:alone, sister and mother live close by
Occupation:previously worked as a manufacturing line but has is
now disabled due to her medical condition.
Tobacco:very infrequent cigarette smoker and has not had a
cigarette in over 15 years
ETOH:denies
Family History:
Father with MI in his 40's and lived into his
70's, Mother with bilateral CEA
Physical Exam:
Pulse:61 Resp:18 O2 sat:96/RA
B/P Right:124/52 Left:150/80
Height:5'1" Weight:244 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]very diminished
Heart: RRR [x] Irregular [] Murmur IV/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] obese
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x], (B)LE mild erythematous rash
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit (L)thrill-(B) bruits vs transmission of
AS-pulses=Right: 2+ Left:2+
Pertinent Results:
[**2178-4-24**] TEE
Conclusions
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The number of aortic
valve leaflets cannot be determined. The aortic valve leaflets
are severely thickened/deformed. A mass is present on the right
coronary cuep of the aortic valve. There is critical aortic
valve stenosis (valve area <0.8cm2). No aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened. There
is severe mitral annular calcification. A likely torn mitral
chord associated with the posterior mitral leaflet is present.
Mild to moderate ([**12-7**]+) mitral regurgitation is seen. There is
no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is AV paced. Normal biventricular
systolic function, though left ventricle is underfilled. There
is a bileaflet prosthesis in the aortic position. It appears
well seated and both leaflets can be seen moving normally. There
is a mobile, loop like echodensity seen in some views of the
left ventricular outflow tract (LVOT) that probably represents
some mitral annular tissue that was mobilized during the
surgical procedure. It may be causing some amount of obstruction
to flow through the LVOT although this can not be clearly
established due to limited views. The maximum gradient through
the LVOT/aortic valve is 16 mmHg with a mean pressure of 7 mmHg
at a cardiac output of 3.5 liters/minute. There is trace aortic
regurgitation seen which is likely the normal washing jets
associated with this valve but this can not be completely
established. The mitral regurgitation may be slightly worse than
pre-bypass. The tricuspid regurgitation is now mild to moderate.
The thoracic aorta is intact s/p decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2178-4-24**] 12:10
?????? [**2169**] CareGroup IS. All rights reserved.
[**2178-5-6**] 05:07AM BLOOD WBC-10.5 RBC-3.94* Hgb-11.2* Hct-35.3*
MCV-90 MCH-28.3 MCHC-31.6 RDW-16.9* Plt Ct-476*
[**2178-5-5**] 03:00AM BLOOD WBC-8.1 RBC-3.59* Hgb-10.4* Hct-32.2*
MCV-90 MCH-28.9 MCHC-32.2 RDW-16.5* Plt Ct-365
[**2178-5-6**] 05:07AM BLOOD Glucose-128* UreaN-45* Creat-1.2* Na-146*
K-4.6 Cl-105 HCO3-32 AnGap-14
[**2178-5-5**] 03:00AM BLOOD Glucose-104* UreaN-48* Creat-1.3* Na-145
K-4.4 Cl-105 HCO3-36* AnGap-8
[**2178-5-6**] 05:07AM BLOOD PT-26.9* INR(PT)-2.6*
[**2178-5-5**] 03:00AM BLOOD PT-34.0* PTT-30.8 INR(PT)-3.4*
[**2178-5-4**] 02:51AM BLOOD PT-25.9* PTT-70.5* INR(PT)-2.5*
[**2178-5-3**] 03:18AM BLOOD PT-18.1* PTT-77.9* INR(PT)-1.6*
[**2178-5-2**] 10:46PM BLOOD PT-16.6* PTT-82.5* INR(PT)-1.5*
[**2178-5-2**] 12:49AM BLOOD PT-15.6* PTT-66.2* INR(PT)-1.4*
[**2178-5-1**] 12:59AM BLOOD PT-15.1* PTT-56.9* INR(PT)-1.3*
[**2178-4-30**] 03:07PM BLOOD PT-15.6* PTT-51.6* INR(PT)-1.4*
[**2178-4-30**] 02:00AM BLOOD PT-14.8* PTT-53.3* INR(PT)-1.3*
[**2178-4-29**] 02:02AM BLOOD PT-16.4* PTT-61.2* INR(PT)-1.4*
[**2178-4-27**] 11:16PM BLOOD PT-18.0* PTT-28.8 INR(PT)-1.6*
[**2178-4-27**] 02:37AM BLOOD PT-17.6* PTT-32.8 INR(PT)-1.6*
Brief Hospital Course:
The patient was brought to the Operating Room on [**2178-4-24**] where
the patient underwent Aortic Valve Replacement (19mm St. [**Male First Name (un) 923**]
mechanical) with Dr. [**Last Name (STitle) **]. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. Urine output decreased, and she became
hemodynamically unstable. The Swan Ganz Catheter was re-placed.
Additionally, she developed pulmonary edema and respiratory
distress and was re-intubted. She remained on Neo and Milrinone
and was given volume. She was anti-coagulated with coumadin and
a heparin bridge for the mechanical valve.
The patient was extubated on POD 3. Later in the day she
developed atrial fibrillation. Amiodarone was given for
chemical cardioversion. She developed a junctional rhythm
requiring pacing. PA pressures rose and pulmonary edema was
shown on CXR. She was re-intubated again. Amiodarone was held.
DobHoff was placed for tube feeding purposes. She remained on a
Lasix drip.
Hemodynamics improved and the patient was weaned from pressors
and extubated.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 12 the patient was ambulating, yet deconditioned, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to [**Location (un) **] House rehab in good
condition with appropriate follow up instructions.
Medications on Admission:
ATENOLOL - (Prescribed by Other Provider) - 25 mg Tablet - 1
(One) Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
(One) Tablet(s) by mouth once a day
METFORMIN - (Prescribed by Other Provider) - 500 mg Tablet - 1
(One) Tablet(s) by mouth daily at dinner time
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 (One) Tablet(s) by
mouth once a day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] - (OTC) -
Dosage uncertain
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
MD to dose daily for goal INR 2.5-3.0, dx: mechanical AVR.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
13. Outpatient Lab Work
Labs: PT/INR
Coumadin for mechanical AVR
Goal INR 2.5-3.0
First draw [**2178-5-7**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
17. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
19. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis
Pneumonia
Hypertension
Type 2 Diabetis Mellitus
Past Surgical History:
s/p tonsillectomy
s/p Cholecystectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2178-5-27**]
1:30
Cardiologist Dr. [**Last Name (STitle) 1918**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 11767**]
Date/Time:[**2178-6-9**] 9:40
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) 2515**] [**Last Name (NamePattern1) **] JR. [**Telephone/Fax (1) 17030**] in [**3-10**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for mechanical AVR
Goal INR 2.5-3.0
First draw [**2178-5-7**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by MD
Completed by:[**2178-5-6**]
|
[
"584.9",
"458.29",
"250.00",
"E878.1",
"427.32",
"518.4",
"V85.42",
"599.0",
"401.9",
"424.1",
"746.4",
"278.01",
"V49.87",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"89.64",
"96.71",
"39.61",
"35.39",
"35.22"
] |
icd9pcs
|
[
[
[]
]
] |
11043, 11145
|
6731, 8587
|
357, 532
|
11314, 11485
|
2879, 6708
|
12357, 13275
|
2059, 2139
|
9234, 11020
|
11166, 11230
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8613, 9211
|
11509, 12334
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11253, 11293
|
2154, 2860
|
297, 319
|
560, 1621
|
1643, 1707
|
1786, 2043
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,721
| 114,618
|
6242
|
Discharge summary
|
report
|
Admission Date: [**2160-6-23**] Discharge Date: [**2160-7-1**]
Date of Birth: [**2076-2-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2160-6-23**] 1. Aortic valve replacement with a [**Street Address(2) 6158**]. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 4041**] tissue valve, reference number [**Serial Number 24303**],and serial number
[**Serial Number 24304**].
2. Coronary artery bypass grafting x2 with the left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the 2nd diagonal artery.
History of Present Illness:
Patient is an 84yo male with history of CAD s/p RCA stents x 2,
PVD s/p RSFA stent with ongoing claudication, known AS with
serial echos now severe with new report of shortness of breath
over the last few months when walking his dog for 20 minutes. He
also reports bilateral claudication.
Past Medical History:
Aortic stenosis
Cholecystectomy
Parotid tumor removed from behind right ear
Arthritis
Mocardial infarction (NSTEMI [**2146**])
Coronary artery disease s/p RCA stent x 2 ( [**2146**],[**2152**])
Peripheral vascular disease s/p RSFA stent ([**2155**])
Hypertension
Hyperlipidemia
Anemia
Cataract removal
Social History:
Independent. Widowed, lives alone with dog (12yo golden
retriever). Walks dog [**Hospital1 **], attends [**Company 3596**] 3x/wk to do eliptical
machine. One son, local. Drives himself to appts.
Lives with: alone
Occupation: retired printing company
Tobacco: 2-3ppd age 16-70's, none current
ETOH: none current
Family History:
Mother deceased age 50's, brain Ca. Father deceased age 69, CAD.
Brother deceased age 50's, liver dz. Brother alive, CAD. Son,
57yo, alive and well.
Physical Exam:
Pre op exam:
Pulse:52 B/P: Right 142/58 Resp: 16, O2 Sat: 97%
Height: 5 feet 7 inches Weight: 150 pounds
General: Alert well developed elderly male in NAD at rest.
Skin: color pale, skin warm and dry, no lesions noted.
HEENT: normocephalic,anicteric, EOMIs. Oropharynx moist.
Neck: supple, trachea midline, no jvd. No carotid bruits noted
Chest: CTA
Heart: III/VI murmur RSB radiating throughout precordium
Abdomen: soft, flat,nontender
Extremities: trace LLE edema, 2+ RLE edema. Right >left
chronically
Neuro: A+O x 3
Pulses:
Femoral: Right cath site Left 2+
Dorsalis Pedal: Right +1 Left +1
Posterior Tibial: Right +1 Left +1
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.0 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.0 cm
Left Ventricle - Fractional Shortening: 0.38 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aorta - Annulus: 2.6 cm <= 3.0 cm
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aorta - Descending Thoracic: *3.1 cm <= 2.5 cm
Aortic Valve - Mean Gradient: 40 mm Hg
Findings
LEFT ATRIUM: Marked LA enlargement. Depressed LAA emptying
velocity (<0.2m/s) No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Mildly dilated
ascending aorta. Mildly dilated descending aorta. Complex (>4mm)
atheroma in the descending thoracic aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Severely
thickened/deformed aortic valve leaflets. Bioprosthetic aortic
valve prosthesis (AVR). Moderate (2+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe
mitral annular calcification.
Pre-op labs:
[**2160-6-23**] 04:01PM GLUCOSE-152* LACTATE-2.0 NA+-136 K+-5.1
CL--118*
[**2160-6-23**] 04:02PM FIBRINOGE-164*
[**2160-6-23**] 04:02PM PT-17.9* PTT-41.0* INR(PT)-1.7*
[**2160-6-23**] 04:02PM PLT COUNT-131*
[**2160-6-23**] 04:02PM WBC-10.8 RBC-2.23*# HGB-6.9*# HCT-20.9*#
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.1
[**2160-6-23**] 05:25PM UREA N-21* CREAT-0.9 SODIUM-143 POTASSIUM-5.0
CHLORIDE-117* TOTAL CO2-19* ANION GAP-12
[**2160-7-1**] 04:38AM BLOOD WBC-11.4* RBC-2.79* Hgb-8.7* Hct-26.2*
MCV-94 MCH-31.3 MCHC-33.3 RDW-14.2 Plt Ct-197
[**2160-7-1**] 04:38AM BLOOD Plt Ct-197
[**2160-7-1**] 04:38AM BLOOD PT-29.2* PTT-108.8* INR(PT)-2.8*
[**2160-7-1**] 04:38AM BLOOD Glucose-113* UreaN-45* Creat-1.4* Na-139
K-4.5 Cl-105 HCO3-25 AnGap-14
[**2160-7-1**] 04:38AM BLOOD Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 11270**] was a same day admission and on [**6-23**] was brought
directly to the operating room where he underwent an aortic
valve replacement and coronary artery bypass graft x 2. Please
see operative report for surgical details. In summary he had: 1.
Aortic valve replacement with a [**Street Address(2) 6158**]. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**] tissue
valve, reference number [**Serial Number 24303**],and serial number [**Serial Number 24304**].
2. Coronary artery bypass grafting x2 with the left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the 2nd diagonal artery. His
cardiopulmonary bypass time was 154 minutes with an aortic
crossclamp time of 134 minutes. he tolerated the operation well
and post operatively was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, woke neurologically intact and extubated. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. On POD2 the patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were removed per cardiac surgery protocol without
complication. He will remain on plavix for his right coronary
stent that was not bypassed. The patient was evaluated by the
physical therapy for assistance with strength and mobility. The
patient had several episodes of post operative atrial
fibrillation and was treated with beta blockers, Amiodarone and
eventually started on Coumadin therapy. On post-operative day
five his right leg, where he had an SFA stent placed in [**2155**],
became acutely painful, pulseless, and cool. A vascular consult
was called and heparin was initiated, following which the
clinical exam improved. The patient is to follow up with Dr.
[**Last Name (STitle) 3407**] as an outpatient. An ultrasound ruled out a deep vein
thrombosis. ABI studies were obtained which showed, significant
aorto right iliac and bilateral SFA disease, significant flow
deficit right lower extremiity, probable right SFA occlusion.
The extremity is still without palpable pulses, but it warmer on
exam. By the time of discharge on POD 8, the patient was
therapeutic on Coumadin therapy with an INR of 2.8. Pain was
controlled with oral analgesics. The patient was discharged to
home with services in good condition with appropriate follow up
instructions for couamdin with PCP and vascular surgery.
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. PleTAL *NF* (cilostazol) 100 mg Oral daily
5. Clopidogrel 75 mg PO DAILY
6. Loperamide 4-6 mg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Aspirin 81 mg PO DAILY
9. flaxseed oil *NF* 1,000 mg Oral daily
10. Multivitamins 1 TAB PO DAILY
11. Fish Oil (Omega 3) [**2147**] mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *8 HOUR PAIN RELIEVER 650 mg 1 Tablet(s) by mouth q6h prn
Disp #*60 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *Adult Low Dose Aspirin 81 mg 1 Tablet(s) by mouth daily Disp
#*60 Tablet Refills:*2
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 Tablet(s) by mouth q 4 h prn Disp #*45
Tablet Refills:*0
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 Tablet(s) by mouth daily Disp #*60
Tablet Refills:*1
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 Tablet(s) by mouth daily Disp #*60
Tablet Refills:*2
6. Loperamide 4-6 mg PO QID:PRN diarrhea
RX *Anti-Diarrheal (loperamide) 2 mg 2-3 tablets by mouth prn
Disp #*60 Tablet Refills:*0
7. Amiodarone 400 mg PO BID
x 7 days, then decrease to 200 mg [**Hospital1 **] x 7 days, then decrease to
200 mg daily
RX *amiodarone 200 mg 2 Tablet(s) by mouth [**Hospital1 **] x 7 days, then
decrease to 1 tab (200 mg) [**Hospital1 **] x 7 days, then decrease to 1 tab
daily (200 mg) Disp #*60 Tablet Refills:*0
8. Furosemide 40 mg PO BID Duration: 10 Days
RX *Lasix 40 mg 1 Tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
9. Warfarin MD to order daily dose PO DAILY16
Tablet Refills:*2
10. Warfarin 0.5 mg PO ONCE Duration: 1 Doses
RX *Coumadin 1 mg 0.5 (One half) Tablet(s) by mouth once Disp
#*1 Tablet Refills:*0
11. Fish Oil (Omega 3) [**2147**] mg PO DAILY
RX *Fish Oil 120 mg-180 mg 1 Capsule(s) by mouth daily Disp #*60
Tablet Refills:*1
12. flaxseed oil *NF* 1,000 mg Oral daily
RX *flaxseed oil 1,000 mg 1 Capsule(s) by mouth daily Disp #*60
Tablet Refills:*1
13. Multivitamins 1 TAB PO DAILY
RX *Daily Value 1 Tablet(s) by mouth daily Disp #*60 Tablet
Refills:*1
14. Metoprolol Tartrate 25 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 Tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
15. Ranitidine 150 mg PO DAILY
RX *Zantac 150 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Aortic stenosis and coronary artery disease s/p Aortic valve
replacement and coronary artery bypass graft x 2
Post operative atrial fibrillation
PMH:
Cholecystectomy
Parotid tumor removed from behind right ear
Arthritis
Mocardial infarction (NSTEMI [**2146**])
s/p RCA stent x 2 ( [**2146**],[**2152**])
Peripheral vascular disease s/p RSFA stent ([**2155**])
Hypertension
Hyperlipidemia
Anemia
Cataract removal
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with Tylenol and Ultram
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema-
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2160-7-31**] 1:30
Cardiologist: Dr. [**Last Name (STitle) 1911**] [**Telephone/Fax (1) 11767**] Date/Time:[**2160-7-14**]
11:20
Vascular: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2160-7-22**] 10:30
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 24305**] in [**4-3**] weeks [**Telephone/Fax (1) 24306**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR 2-2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr.
[**Last Name (STitle) 24307**] to phone fax
Completed by:[**2160-7-1**]
|
[
"401.9",
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"V16.8",
"733.00",
"440.21",
"412",
"288.60",
"285.1",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.11",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
10061, 10144
|
5048, 7570
|
329, 762
|
10600, 10829
|
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1102, 1405
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1421, 1734
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,246
| 197,038
|
44666
|
Discharge summary
|
report
|
Admission Date: [**2188-10-11**] Discharge Date: [**2188-10-17**]
Date of Birth: [**2132-4-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Pleurisy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 56 yo M with a history of hemachromatosis c/b
CVA [**96**] year ago with no residual deficits, who presented to the
ED today complaining of several days of left sided chest pain
that is worse with inspiration. The pain is sharp and
nonradiating and is worse with sitting up. It's constant. He
also complains of shortness of breath, but he feels this is
because it was very painful to breath at all. He has a cough
productive of brown sputum. He admitted to vomiting earlier in
the week. He has had decreased appetite and poor PO intake for
the last 2 days. He denies f/c, n/d, diaphoresis, palpitations.
.
In the ED, the patient's VS were 97.3, 101, 130/83 satting 95%6L
nc. He underwent CTA to r/o PE, which was negative, but showed a
dense LLL pna. His labs were notable for a leukocytosis to
14,000 with 22 bands, a creatinine of 1.7, and a lactate of 3.5.
He was given 3L NS and a dose of levofloxacin 750mg x 1. He also
received morphine, toradol and dilaudid for pain control.
Lactate improved to 2.5 with IVF. Cardiac enzymes were negative
and EKG was without ischemic changes.
.
On the floor, the patient's pain was much better controlled. He
denied shortness of breath, fevers/chills. He noted that as long
as his pain was controlled, his breathing felt comfortable. He
felt very thirsty. Shortly after arrival to the floor the
patient triggered for tachycardia to 150 while attempting to
give a sputum sample. Telemetry monitoring showed a narrow
complex tachycardia with p waves present that lasted for about 6
minutes. His tachycardia broke with a valsalva maneuver and his
heart rate returned to the 90s. He was transfered to the ICU
for closer monitoring.
Past Medical History:
Hemochromatosis
HTN (used to be on lisinopril, stopped taking meds)
s/p CVA [**96**] years ago. No residual deficits.
Nephrolithiasis
Social History:
Patient smoked 2.5 ppd x 27 years, but quit 17 years ago. Does
not drink etoh or use illicits. No IVDU. Lives alone.
Family History:
NC
Physical Exam:
VS: T 96.6, HR 106, BP 138/78, 91% on 6L NC
Gen: NAD, ruddy complexion, pleasant
HEENT: EOMI, PERRL, OP clear, MM dry.
Neck: No JVD, no LAD
Cor: RRR no m/r/g
Pulm: No breath sounds at the left base, +dullness to percussion
and reduced fremitus at LLL. Diffuse musical wheezing and
rhonchi.
Abd: soft +BS, NT/ND, No HSM
Extrem: no c/c/e, strong pulses.
Skin: no rashes
Neuro: CN II-XII intact bilaterally. Strength is [**3-24**]
bilaterally. Sensation to LT in tact. No tremor. A&Ox3.
Pertinent Results:
Admission Labs:
WBC-14.0*# RBC-4.25* Hgb-16.6 Hct-45.3 MCV-107* MCH-39.1*
MCHC-36.7* RDW-13.5 Plt Ct-107*
Neuts-59 Bands-22* Lymphs-3* Monos-12* Eos-0 Baso-0 Atyps-0
Metas-3* Myelos-1*
Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL
[**Name (NI) 2849**] [**Name (NI) 2850**]
PT-18.2* PTT-36.8* INR(PT)-1.7*
Glucose-141* UreaN-31* Creat-1.7* Na-133 K-4.4 Cl-96 HCO3-24
ALT-48* AST-32 LD(LDH)-157 CK(CPK)-74 AlkPhos-107 Amylase-15
TotBili-3.6* DirBili-1.5* IndBili-2.1 Lipase-15
CK-MB-4 cTropnT-<0.01
Albumin-3.2* Calcium-8.2* Phos-3.3 Mg-1.8 Iron-82
calTIBC-172* Ferritn-GREATER TH TRF-132*
HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE
HCV Ab-NEGATIVE
Type-ART Temp-35.7 pO2-85 pCO2-45 pH-7.32* calTCO2-24 Base XS--3
Intubat-NOT INTUBA
Lactate-3.5*
Studies:
[**2188-10-11**] EKG: Sinus tachycardia. Early repolarization changes.
Otherwise, findings are within normal limits. Compared to the
previous tracing of [**2171-3-14**] sinus tachycardia is new.
[**2188-10-11**] CXR - CONCLUSION: Dense pneumonic consolidation in the
left lower lobe. Please ensure followup to clearance.
[**2188-10-11**] CTA chest - CONCLUSION:
1. Dense pneumonic consolidation involving most of the left
lower lobe,
please ensure followup to clearance.
2. Up to 4 mm scattered pulmonary nodules in the right lower
lobe should be followed up with a chest CT in six months if the
patient is at high risk of cancer. Otherwise, followup is
recommended with a chest CT in 12 months.
3. Contour deformities in the liver and splenic enlargement
consistent with cirrhosis.
[**2188-10-12**] RUQ ultrasound - IMPRESSION:
1. Cirrhosis.
2. Normal Doppler evaluation of the hepatic vessels.
[**2188-10-13**] TTE - The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is low normal (LVEF 55%). The
estimated cardiac index is normal (>=2.5L/min/m2). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened (left coronary leaflet) but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2184-6-21**], the findings are similar.
If the clinical suspicion for iron deposition in the heart is
moderate or high, a cardiac MRI ([**Telephone/Fax (1) 9559**]) is suggested to
assess T2*.
[**2188-10-15**] 06:35AM BLOOD WBC-6.8 RBC-3.72* Hgb-14.5 Hct-39.8*
MCV-107* MCH-38.9* MCHC-36.4* RDW-13.6 Plt Ct-118*
[**2188-10-15**] 06:35AM BLOOD Glucose-96 UreaN-18 Creat-0.7 Na-135
K-4.2 Cl-101 HCO3-24 AnGap-14
[**2188-10-13**] 03:29AM BLOOD ALT-37 AST-30 LD(LDH)-148 AlkPhos-95
TotBili-1.8*
[**2188-10-14**] 07:15AM BLOOD VitB12-1161* Folate-4.3
[**2188-10-12**] 01:35AM BLOOD calTIBC-172* Ferritn-GREATER TH TRF-132*
[**2188-10-13**] 04:18PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2188-10-13**] 03:29AM BLOOD AFP-1.4
[**2188-10-13**] 03:29AM BLOOD HAV Ab-NEGATIVE
[**2188-10-12**] 01:35AM BLOOD HCV Ab-NEGATIVE
[**10-14**] EGD
Findings: Esophagus:
Mucosa: Streaky continuous erythema of the mucosa with no
bleeding was noted in the gastroesophageal junction. These
findings are compatible with esophagitis. A cold forceps biopsy
was performed for histology at the gastro-esophageal junction.
Protruding Lesions 4 cords of grade I varices were seen in the
lower third of the esophagus and middle third of the esophagus.
Stomach:
Mucosa: Erythema of the mucosa was noted in the antrum. These
findings are compatible with gastritis. Two cold forceps
biopsies were performed for histology at the stomach antrum.
Duodenum:
Mucosa: Erythema of the mucosa was noted in the duodenal bulb
compatible with duodenitis.
Impression: Erythema in the gastroesophageal junction compatible
with esophagitis (biopsy)
Varices at the lower third of the esophagus and middle third of
the esophagus
Erythema in the antrum compatible with gastritis (biopsy)
Erythema in the duodenal bulb compatible with duodenitis
Otherwise normal EGD to second part of the duodenum
Recommendations: Avoid all NSAIDS and [**Doctor Last Name **]-2 inhibitors. Take
tylenol for pain (max dose of 2 grams per day). Nadolol 20 mg po
daily. Protonix 40 mg po daily.
Brief Hospital Course:
Mr. [**Known lastname **] is a 56 year old male with a history of
hemochromatosis and CAP, who presents with LLL pneumonia and
hypoxia.
# Sepsis from LLL pneumonia - The patient was admitted with an
elevated lactate, hypothermia, leukocytosis with marked
bandemia, acute renal failure, hypoxia, and CT findings
consistent with LLL pneumonia. Given his clinical picture, he
was initially double-covered with levofloxacin and ceftraxone.
Ceftriaxone was discontinued on [**10-13**] given his marked clinical
improvement. A sputum sample was obtained on admission,
however, it was not a satisfactory specimen for analysis. The
patient was given dilaudid for pain control. Patient no longer
had pleuritic chest pain on discharge. He was discharged on
Levofloxacin to complete a 10 day course, and combivent inhaler.
-He should receive pneumovax, influenza vaccine, and hepatitis B
vaccine as an outpatient given his history of pneumonia.
.
# HTN - has hx of HTN and LVH on echo; would like to better
control, currently not on any medicines. Patient was restarted
on lisinopril 10mg po qd, HCTZ 12.5mg qd, and nadolol 40mg
qd(for esophageal varices).
# Acute Renal Failure ?????? The patient presented with acute renal
failure with a creatinine elevated to 1.7. This was likely
secondary to dehydration given poor PO intake prior to admission
and resolution with IVF. On discharge Creatinine was 0.7 (at
baseline).
# Hemochromatosis: The patient has not had follow-up for his
hemachromatosis for several years (previously was followed by
Dr. [**Last Name (STitle) **] and has not gone in for therapeutic phlebotomy in
several years because he lost his insurance. A hematology
consult was requested. He will follow up with Dr. [**Last Name (STitle) **] as an
outpatient.
# Cirrhosis: The patient had evidence of cirrhosis on CT scan
and a subsequent RUQ ultrasound study with an elevated INR and
total bili. Portal blood flow was normal. His cirrhosis is
likely secondary to hemochromatosis given his ferritin > [**2179**].
Hepatitis B & C serologies were negative and the patient denied
alcohol abuse. Hepatology was consulted. Screening EGD was
done, and stage 1 esophageal varices were noted in the mid/lower
esophagus. Patient was started on nadolol. He was also found to
have gastritis, and was started on Protonix.
# Thrombocytopenia - The patient has splenomegaly on CT scan.
Unclear whether the thrombocytopenia is secondary to splenic
sequestration vs. marrow infiltration vs. sepsis. His platelet
count was monitored, and came up to 187 on discharge.
# Pulmonary nodules - discovered on CT scan. [**Month (only) 116**] be secondary to
infection? He Should obtain a repeat CT scan in [**5-1**] months to
evaluate for interval changes or resolution.
# Thyroid function tests: TSH was checked and was found to be
8.3. Please recheck TSH and T4 as an outpatient and treat
accordingly.
Medications on Admission:
None
Discharge Medications:
1. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: Please do not drive after having
taken this medication.
Disp:*20 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation three times a day for 3 days.
Disp:*1 puffer* Refills:*0*
8. oxygen
2L continuous. Pulse dose for portability.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left lower lobe pneumonia
cirrhosis secondary to hemochromatosis
esophageal varices
hypertension
thrombocytopenia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a severe pneumonia. You were treated with
antibiotics and closely monitored in the intensive care unit.
You were also evaluated by hematology for your hemachromatosis.
You also have a cirrhotic liver and esophageal varices which
puts you at risk of having a major bleed from your esophagus.
You were started on Nadolol for your esophageal varices. It is
essential that you take your medications as directed.
Please call your doctor or go to the emergency room if you have
shortness of breath, fevers, difficulty breathing, bleeding,
abdominal pain, headache, or chest pain. If you have any other
symptoms that concern you please call your doctor.
It was a pleasure caring for you!
Followup Instructions:
Your primary care doctor will need to evaluate your pulmonary
nodules with a CT scan, and also give you a hepatitis B vaccine.
You will also have to have your thyroid function tests checked.
You have an appointment with Dr. [**Last Name (STitle) **] your hematologist on
[**11-4**] at 9am. The clinic phone number is [**Telephone/Fax (1) 14703**].
You have an appointment with Dr. [**Last Name (STitle) 9746**] in hepatology on
[**11-10**] at 10am. You have an appointment with your primary
care doctor Dr. [**First Name (STitle) 3441**] on [**11-24**] at 3:30pm. The clinic number
is [**Telephone/Fax (1) 1300**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2188-10-17**]
|
[
"427.89",
"238.71",
"584.9",
"486",
"511.89",
"275.0",
"799.02",
"276.1",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11475, 11532
|
7530, 10443
|
325, 331
|
11690, 11699
|
2902, 2902
|
12453, 13228
|
2378, 2382
|
10498, 11452
|
11553, 11669
|
10469, 10475
|
11723, 12430
|
2397, 2883
|
277, 287
|
359, 2068
|
2918, 7507
|
2090, 2226
|
2242, 2362
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,642
| 195,999
|
17632+17633
|
Discharge summary
|
report+report
|
Admission Date: [**2197-4-26**] Discharge Date: [**2197-5-4**]
Date of Birth: [**2130-3-5**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 67-year-old man was
referred for cardiac catheterization after positive stress
test. He had increased shortness of breath for the past 6-8
months with walking or climbing stairs and denies angina or
claudication. An exercise test on [**4-19**] was stopped
secondary to shortness of breath and the electrocardiogram
revealed ST depressions in II, III, aVF, and V5 and V6. The
Myoview revealed moderate reversible anteroseptal defects.
PAST MEDICAL HISTORY:
1. History of hypertension.
2. History of hypercholesterolemia.
3. History of Crohn's disease.
4. History of penile cancer.
5. Status post abdominal surgery for bowel perforation.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po q day.
2. Pravachol 80 mg po q day.
3. B12 1,000 mg po q day.
4. Atenolol 50 mg po q day.
ALLERGIES: Percocet and Lipitor.
SOCIAL HISTORY: He smoked in the past, quit 15 years ago.
He drinks 1-2 drinks per week and lives with his wife.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: On physical exam he is a
well-developed and well-nourished male in no apparent
distress. Vital signs stable, afebrile. HEENT is
normocephalic, atraumatic. Extraocular movements are intact.
Oropharynx is benign. Neck is supple, full range of motion,
no lymphadenopathy or thyromegaly. Carotids are 2+ and equal
bilaterally without bruits. Lungs are clear to auscultation
and percussion. Cardiovascular examination regular, rate,
and rhythm, normal S1, S2 with no murmurs, rubs, or gallops.
Abdomen was soft and nontender with positive bowel sounds, no
masses or hepatosplenomegaly. He had a well-healed midline
scar to the right umbilicus. His extremities were warm and
well perfused without clubbing, cyanosis, or edema. He had
no varicosities. His pulses were 2+ and equal bilaterally
throughout. Neurologic examination was nonfocal.
STUDIES: On [**4-26**], he underwent cardiac catheterization
which revealed the left ventricle had no mitral
regurgitation, mild antero-apical hypokinesis, and a normal
ejection fraction. The left main coronary artery had an 80%
distal stenosis involving the ostial left anterior descending
artery. Left anterior descending artery had an 80% ostial
stenosis. Left circumflex had no significant disease. Right
coronary artery: No significant disease and the ramus had no
significant disease.
Dr. [**Last Name (STitle) 70**] was consulted, and on [**2197-4-27**], the patient
underwent a CABG x3 with LIMA to the left anterior descending
artery, reverse saphenous vein graft to the diagonal and the
OM, cross-clamp time was 79 minutes, total bypass time 44
minutes. The patient was transferred to the CSRU on
Neo-synephrine and propofol.
He had a stable postoperative night, and was extubated. He
was on an insulin drip and Neo-Synephrine. On postoperative
day two, he went into atrial fibrillation and was started on
amiodarone. His rate was controlled in the 60s and he
converted to sinus rhythm.
The chest tubes were discontinued on postoperative day #3,
and he continued to be in atrial fibrillation in a controlled
rate, and on postoperative day #4, he was transferred to the
floor in stable condition.
His wires were discontinued on postoperative day #5. He
continued to have a stable postoperative course and was being
anticoagulated, and was discharged to home on postoperative
day #7 in stable condition.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po bid.
2. Aspirin 81 mg po q day.
3. Amiodarone 400 mg po q day x2 weeks, then decrease to 200
mg po q day x4 weeks.
4. Pravachol 890 mg po q day.
5. Coumadin 5 mg po q day for an INR goal of [**1-29**].5.
LABORATORIES ON DISCHARGE: White count 7,500, hemoglobin
30.8, platelets 258. Sodium 134, potassium 4.4, chloride
100, CO2 26, BUN 23, creatinine 1.3, and blood sugar 206.
FOLLOW-UP INSTRUCTIONS:
1. He will be followed by Dr. [**Last Name (STitle) **] in [**12-29**] weeks, and have
his coags followed by Dr. [**Last Name (STitle) **].
2. He will see Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3116**]
MEDQUIST36
D: [**2197-5-4**] 11:13
T: [**2197-5-4**] 11:36
JOB#: [**Job Number 49110**]
Admission Date: [**2197-4-26**] Discharge Date: [**2197-5-6**]
Date of Birth: [**2130-3-5**] Sex: M
Service: CARD-[**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 67 year old male who
presented to his primary care provider with [**Name Initial (PRE) **] chief complaint
of progressive dyspnea on exertion over the past 18 months.
The patient's wife reported that the patient has become
progressively more and more dyspneic upon walking up a flight
of stairs and has episodes every day that resolve with rest.
The patient denied ever experiencing any chest pain in
association with these episodes. The patient subsequently
underwent a stress test in [**2197-3-28**], which was stopped
after six minutes and 34 seconds of the [**Doctor First Name **] protocol
secondary to shortness of breath. The patient did not
experience any chest pain during this test.
The patient's EKG at this time demonstrated [**Street Address(2) 49111**] depressions in leads II, III, AVF and V5 through
6 during the last stage of exercise. In the Recovery Room,
the patient developed [**Street Address(2) 49112**] depressions
in leads I, II, III, AVF and V1 through V6, with T wave
inversions which persisted until 12 minutes after exercise.
Imaging studies demonstrated moderate reversible anterior and
septal wall defects. The patient's ejection fraction was
estimated to be 43%. The patient was subsequently referred
to [**Hospital1 69**] for an outpatient
cardiac catheterization to evaluate heart function.
The catheterization took place on [**2197-4-26**], and
demonstrated 80% distal stenosis of the left main coronary
artery and 80% occlusion of the left anterior descending.
Ejection fraction was noted to be 49%. The patient was
subsequently admitted to the [**Hospital Unit Name 196**] service under the direction
of Dr. [**First Name (STitle) **] K. W. Ho, on [**2197-4-26**] for further
evaluation and management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Penile cancer status post resection.
4. Crohn's Disease status post resection.
5. Chronic cough.
HOME MEDICATIONS:
1. Aspirin.
2. Pravachol.
3. B12.
4. Atenolol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives with his wife and works
as a cashier. The patient has a remote history of smoking
cigarettes which he quit approximately 15 years ago. He
drinks one to two alcoholic drinks per week. No intravenous
drug use history.
HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**]
Service on [**2197-4-26**], under the direction of Dr. [**Last Name (STitle) **]. A
Cardiothoracic Surgery consultation was obtained upon
admission; following an extensive discussion with the patient
and his family regarding the relative risks and benefits of
surgery, the patient agreed to undergo coronary artery bypass
graft on [**2197-4-27**].
On [**2197-4-27**], the patient underwent a coronary artery
bypass graft times three. Anastomoses included left internal
mammary artery to left anterior descending; saphenous vein
graft to diagonal; and saphenous vein graft to obtuse
marginal. The patient tolerated the procedure well and had a
bypass time of 79 minutes and a cross clamp time o4 44
minutes. The patient's pericardium was left open;
intraoperative lines placed included a right radial and right
internal jugular line; both ventricular and atrial wires were
placed; mediastinal and left pleural tubes were placed.
The patient was subsequently transferred from the Operating
Room to the Cardiac Surgery Recovery Unit, intubated, for
further evaluation and management. On transfer, the
patient's mean arterial pressure was 80; his central venous
pressure was 6; his PAD was 13 and his [**Doctor First Name 1052**] was 17. The
patient was atrially paced at a rate of 88 beats per minute.
Active drips on transfer included Neo-Synephrine and
Propofol. Following arrival in the CSRU, the patient was
successfully weaned and extubated. His postoperative
hematocrit was noted to be 36.1. In the CSRU, the patient
progressed well clinically. He was advanced successfully to
oral medications without adverse events and was successfully
weaned from pressor drips. The patient's chest tubes were
successfully removed without complication as were his pacer
wires, after which point he was cleared for transfer to the
Floor on postoperative day number four.
The patient was subsequently admitted to the Cardiothoracic
Service under the direction of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**].
Postoperatively, the patient's clinical course was
uneventful. The patient was evaluated by Physical Therapy
who deemed him an appropriate candidate for eventual
discharge to home following completion of the acute medical
care.
The patient was noted to develop atrial fibrillation
refractory to medical therapy, after which point he was begun
on a Coumadin anti-coagulation pathway. As the patient was
progressively dosed with Coumadin for a therapeutic INR of
over 2.0, the patient was noted to be successfully
transitioned to a full regular diet and his pain was
controlled adequately with oral pain medications. The
patient was noted to be independently ambulatory and was
noted to be independently productive of adequate amounts of
urine for the duration of his stay.
By postoperative day number eight, the patient was noted to
be afebrile and stable. His incisions were noted to be
healing well with Steri-Strips intact and no evidence of
cellulitis or purulent drainage. The patient was noted to be
fully tolerant of a regular diet and his pain was well
controlled.
Following a final INR [**Location (un) 1131**] of 2.3, the patient was cleared
for discharge to home on postoperative day number 9, [**2197-5-6**], with instructions for follow-up.
CONDITION ON DISCHARGE: The patient is to be discharged
home with instructions for follow-up.
DISCHARGE STATUS: Stable.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Amiodarone 400 mg p.o. q. day times 14 days, followed by
200 mg p.o. q. day times four weeks.
3. Vicodin one to two tablets p.o. q. four to six hours
p.r.n.
4. Pravastatin 80 mg p.o. q. day.
5. Coumadin 5 mg p.o. q. day times four days, with the
patient's dose to be titrated thereafter by his primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DISCHARGE INSTRUCTIONS:
1. The patient is to maintain his incisions clean and dry at
all times.
2. The patient may shower but should pat-dry incisions
afterwards; no bathing or swimming until further notice.
3. The patient is to resume a cardiac diet.
4. The patient has been instructed to limit physical
activities; no heavy exertion.
5. No driving while taking prescription pain medications.
6. The patient is to have his Coumadin dosage schedule
managed by his primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; the
patient is to receive biweekly blood draws on Mondays and
Thursdays beginning [**2197-5-8**], and is to call Dr. [**Last Name (STitle) **]
with his results following each blood draw for subsequent
modification of his Coumadin dosing schedule for a target INR
of 2.0.
7. The patient is to have additional primary care physician
[**Name9 (PRE) 702**] as needed.
8. The patient is to follow-up with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] in
Cardiology within three to four weeks.
9. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] six
weeks following discharge.
The patient is to call to schedule all appointments.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1053**]
MEDQUIST36
D: [**2197-5-6**] 15:39
T: [**2197-5-6**] 16:08
JOB#: [**Job Number 49113**]
|
[
"V10.49",
"414.01",
"427.31",
"401.9",
"555.9",
"E878.2",
"411.1",
"997.1",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"88.56",
"36.12",
"88.53",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
1109, 1127
|
10525, 10987
|
830, 977
|
7015, 10376
|
11011, 12596
|
6649, 6740
|
1185, 3561
|
3837, 3984
|
1147, 1162
|
4701, 6461
|
4008, 4671
|
6483, 6631
|
6758, 6996
|
10402, 10502
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,316
| 141,193
|
34257
|
Discharge summary
|
report
|
Admission Date: [**2141-2-27**] Discharge Date: [**2141-3-3**]
Date of Birth: [**2085-2-5**] Sex: F
Service: NEUROLOGY
Allergies:
Adhesive Tape / Ativan
Attending:[**First Name3 (LF) 5378**]
Chief Complaint:
shortness of breath and neck weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Patient is a 56 yo RHW with hx of MuSK Ab positive MG here
from [**Hospital 78874**] clinic with increased respiratory trouble concerning
for MG exacerbation. Per patient, she developed worsening
dyspnea on exertion with some tightness in chest about 2 weeks
ago. In addition, she reports that her upper body felt heavier
and more lead like. She spoke with Dr. [**Last Name (STitle) 78875**] (primary
neurologist) who recommended increasing prednisone from 10 to 30
and increasing Imuran from 200 to 250. She was also scheduled
for short IVIg therapy which started on [**2-23**]. She reports that
with the above change in medications, upper body heaviness
appears to improve but she reports that her respiratory issues
only worsened especially over the weekend.
Patient also had another kidney stone (2mm if L ureter) which
started on [**2-22**] - the days she was supposed to begin IVIg.
Hence,
her IVIg was postponed to the next day and patient came to the
ED
where she received Percocet which she has taken ~[**2-23**] doses over
the past 5 days.
ROS otherwise negative including diplopia, ptosis, dysphagia or
falls. She also denies any fever/chills, N/V/D, or sick
contact.
She feels that there may have been some urinary symptoms but she
has baseline/chronic problems from prolapsed bladder and
cystocele hence she is not sure if its worse than usual.
Patient reports that her last intubation/MS flare may be about 1
year ago around the time her replaced trach stent was removed.
She was initially stented in [**1-30**] because she was not able to be
weaned off the ventilator. She has been followed per Dr.
[**Last Name (STitle) 557**]
and has been on Mestinon, Imuran and Prednisone. Prior to the
increase 2 weeks ago, she was actually tapering down on her
prednisone.
Past Medical History:
1. Myasthenia [**Last Name (un) 2902**] - MuSK Ab+, initial symptoms (dyspnea,
diplopia, neck weakness) in [**2139-1-23**]. Transferred to
[**Hospital1 18**] ICU in [**2139-4-23**] in myasthenic crisis. Underwent IVIg
(at
[**Hospital6 2561**] prior to transfer) then plasmapheresis at
that time,
also started on prednisone and CellCept. Due to difficulty to
wean, she also underwent tracheostomy and placement of a PEG
tube
at that time.
2. Tracheobronchomalacia status post tracheal stent in [**2139-4-23**] - since replaced then removed.
3. GERD and hiatal hernia.
4. History of nephrolithiasis.
5. Anxiety.
6. Status post partial hysterectomy.
7. Status post bladder suspension at age 29.
8. Cystocele.
9. DM - prednisone induced.
Social History:
Lives with son - does not work but was a former case manager.
No tobacco, EtOH or illicit drug use.
Family History:
No FH of MG - multiple members with DM.
Physical Exam:
T 99.1 BP 130/80 HR 80 RR 20 O2Sat 98% 2L NC NIF -80 VC 0.8L
Gen: Sitting in the ED stretcher - mildly anxious appearing.
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM.
CV: RRR, no murmurs/gallops/rubs
Lung: Clear
Abd: +BS, soft, nontender
Ext: No edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. No right left
confusion. No evidence of apraxia or neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. No ptosis.
III, IV & VI: Extraocular movements intact bilaterally, no
nystagmus. No diplopia with extended upgaze.
V: Sensation intact to LT and PP.
VII: Facial movement symmetric.
VIII: Hearing intact to finger rub bilaterally.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Normal bulk and tone bilaterally. No observed myoclonus or
tremor. No asterixis or pronator drift - reports increased
dyspnea if arms are extended out.
Neck Ext Flex [**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF TE TF
R 3+ 5 4+ 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5
Right deltoid weakens to 4+ with repetition. Neck extensor
appears to be giveway weakness from pain but unclear why neck
extension causes pain.
Sensation: Intact to light touch, pinprick, vibration, cold and
proprioception throughout.
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: FTN, FTF and RAMs normal.
Gait: Narrow based, steady. Romberg negative.
Pertinent Results:
[**2141-2-27**] 10:35AM BLOOD WBC-4.7 RBC-4.14* Hgb-12.1 Hct-37.9
MCV-92 MCH-29.3 MCHC-32.0 RDW-20.2* Plt Ct-244
[**2141-2-28**] 02:28AM BLOOD PT-15.2* PTT-37.8* INR(PT)-1.3*
[**2141-2-27**] 10:35AM BLOOD Glucose-134* UreaN-23* Creat-0.8 Na-143
K-3.7 Cl-102 HCO3-35* AnGap-10
[**2141-2-27**] 10:35AM BLOOD CK(CPK)-45
[**2141-2-27**] 10:35AM BLOOD cTropnT-<0.01
[**2141-2-28**] 02:28AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.6
[**2141-2-27**] 12:40PM BLOOD Type-ART pO2-109* pCO2-52* pH-7.41
calTCO2-34* Base XS-7
[**2141-2-28**] 01:10AM BLOOD Type-ART O2 Flow-2 pO2-71* pCO2-56*
pH-7.40 calTCO2-36* Base XS-7
Brief Hospital Course:
Ms. [**Known lastname 7518**] is a 56 year old right handed woman hx of MUSK Ab
positive myasthenia [**Last Name (un) 2902**] (diagnosed in [**2138**]), history of
tracheomalasia, and multiple prior intubations who was sent to
the [**Hospital1 18**] ED from the IVIG infusion clinic due to concern for
respiratory distress.
At baseline she has SOB with exertion. Two weeks ago she noticed
increased SOB with exertion and a feeling of chest tightness.
She feels more fatigued in the afternoon. When walking she had
more trouble keeping her head up than when she was sitting. She
was given IVIG treatment last week. She received IVIG 20 g on
[**2-22**] g on [**2-23**], and 50 g on [**2-24**]. She was at the IVIG infusion
clinic on [**2-27**] for another treatment. The patient was noted to be
short of breath and was sent to the ED.
Patient's examination was notable for weakness of neck extensors
and mild fatiguable weakness at the deltoids. She had no ptosis
or diplopia with sustained upgaze and was able to count to 36 in
one breath. Her NIF was -80 and vital capacity was 0.8 L. It
was thought her presentation was consistent with an exacerbation
of her myasthenia [**Last Name (un) 2902**] and she was admitted to the neurology
ICU.
Hospital course by problem
Neurology:
Routine laboratory work, chest x-ray, and urinalysis showed no
infectious precipitant to her exacerbation. On hospital day #1
the patient was given 40g IVIG, which completed a total course
of 160 g (she received 120 g as an outpatient). She was
continued on her home dose of prednisone, immuran, and mestinon.
She reported subjective improvement in her shortness of breath
and proximal muscle strength each day. The patient was
transferred out of the ICU to the floor on hospital day #3 and
subsequently discharged on HD#4. She was scheduled for follow
up with Dr. [**Last Name (STitle) 557**] in the neurology clinic on [**3-21**].
Respiratory:
The patient's NIF and vital capacity were checked q4h while in
the ICU. Her NIF had been relatively stable at -80 and her
vital capacity fluctuated between 0.45 and 0.8. At time where
she was found to have a low vital capacity she was still able to
count to 20 in one breath. An ABG at that time showed a pCO2 of
56. She was maintained on room air and did not require
intubation. BIPAP was attempted multiple times, but was not
tolerated by the patient.
The patient was also evaluated by interventional pulmonology
given her history of tracheomalasia. They thought her
presentation was more consistent with a MG exacerbation rather
than her tracheomalasia. The patient did have a tracheal stent
placed in the past which was subsequently removed. They
recommended outpatient follow-up for consideration of a new
stent placement. However, as this would require general
anesthesia, it was recommended to be avoided during times of
concern for a MG exacerbation. She will follow up as an
outpatient in 2 weeks. At the time of discharge, whe was able
to count to 40 with a single breath, but her VC was documented
as low as .65L.
Cardiovascular:
The patient was noted on telemetry to be tachycardic to 150s
upon ambulation. This was attributed to her MG. Her exercise
tolerance improved throughout her hospital course. She
continued to have some tachycardia with ambulation which was
felt to be related to her pulmonary function as well.
Endocrine:
The patient was continued on her home lantus and lispro for
diabetes. Her fingersticks were running in the 200s in the ICU,
and her lantus was increased by 4 units to 18 units qAM. Her
insulin regimen may continue to be adjusted to ensure strict
glucose control.
Medications on Admission:
1. ALENDRONATE [FOSAMAX] - 70 mg Tablet Sunday
2. AZATHIOPRINE [IMURAN] - 150/100
3. ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg daily
4. FLUTICASONE [FLONASE] - 50 mcg Spray [**Hospital1 **]
5. FUROSEMIDE - 20 mg Tablet daily
6. HYOSCYAMINE SULFATE - 0.125 mg Tablet TID with Mestinon
7. INSULIN GLARGINE [LANTUS] - 14u daily
8. INSULIN LISPRO [HUMALOG] - 4 units before meals.
9. PAROXETINE HCL [PAXIL] - 20mg bedtime
10. POTASSIUM CHLORIDE [K-DUR] - 20 mEq [**Hospital1 **]
11. PREDNISONE - 30mg daily
12. PYRIDOSTIGMINE BROMIDE [MESTINON] - 60 mg QID
13. RANITIDINE HCL - 150 mg bedtime
14. CALCIUM CARBONATE [CALCIUM 500] TID
15. DEXTROMETHORPHAN-GUAIFENESIN [MUCINEX DM] - 1,200 mg-60 mg
Tab [**Hospital1 **]
16. VITAMIN B12-VITAMIN B1 daily
Discharge Medications:
1. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DINNER
(Dinner).
3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
5. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual four times a day as needed for
with mestinon.
6. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day) as needed for to
manage secretions.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
13. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO three times a day.
14. Vitamin B12-Vitamin B1 Oral
15. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous qAM.
16. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Myasthenia [**Last Name (un) **]
Tracheomalacia
Diabetes
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Neurologic exam was notable for 4+/5 weakness at the next
extensors, and right deltoid, triceps with fatigueability.
Discharge Instructions:
You were admitted for increasing shortness of breath and
weakness. This was thought to be consistent with your
myasthenia [**Last Name (un) 2902**]. You completed a course of IVIG and were
continued on your prednisone, immuran, and mestinon.
Your blood sugars where noted to be elevated and your lantus
dose was increased to 18units in the morning.
You should follow up with Dr. [**Last Name (STitle) 557**] on [**3-21**]. In
addition, You should follow up with interventional pulomonology
in the next few weeks; you will be contact[**Name (NI) **] with the timing of
thia appoitment.
You have been scheduled for follow up with your primary care
doctor, Dr. [**First Name (STitle) **], to discuss this hospitalization.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Name (STitle) 557**] ([**Telephone/Fax (1) 13172**].
[**2141-3-21**] 9:30am
Dr. [**Last Name (STitle) 78876**] you should be contact[**Name (NI) **] regarding the timing of this
appointment
Dr. [**First Name (STitle) 9466**] [**Name (STitle) **] ([**Telephone/Fax (1) 250**]
Date/Time:[**2141-3-29**] 10:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5379**] MD, [**MD Number(3) 5380**]
Completed by:[**2141-3-3**]
|
[
"519.19",
"358.01",
"300.00",
"530.81",
"E932.0",
"786.09",
"249.00",
"V58.67",
"553.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11485, 11491
|
5645, 9309
|
320, 326
|
11592, 11592
|
5019, 5622
|
12605, 13107
|
3041, 3083
|
10105, 11462
|
11512, 11571
|
9335, 10082
|
11857, 12582
|
3098, 3384
|
243, 282
|
354, 2148
|
3739, 5000
|
11607, 11833
|
3408, 3408
|
2170, 2907
|
2923, 3025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,895
| 100,696
|
35462
|
Discharge summary
|
report
|
Admission Date: [**2166-2-25**] [**Year/Month/Day **] Date: [**2166-3-14**]
Date of Birth: [**2125-12-1**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4533**]
Chief Complaint:
continued intubation/monitoring s/p R radical nephrectomy
Major Surgical or Invasive Procedure:
R radical nephrectomy and s/p intubation
History of Present Illness:
40yo man with h/o ascending aortic dissection in [**2160**] s/p repair
and St. Jude's valve placement on coumadin ([**2160**]), s/p recent R
perinephric bleed requiring IR embolization([**11/2165**]), CRI with
h/o ATN requiring CVVH post procedure, HTN, who was admitted to
[**Hospital Unit Name 153**] for monitoring after R radical nephrectomy and removal of
large renal mass.
.
The patient was admitted to the OR with urology service for R
radical nephrectomy and removal of large renal mass (13cm)
suspicious for malignancy today. The procedure was difficult but
without complications, and 150cc 250% albumin. Specimen sent for
pathology. Patient was bridged with heparin prior to procedure.
Given history of prior history of ATN and fluid overload
requiring CVVH during last admission ([**Month (only) **]-[**Month (only) **]/[**2165**]), patient was
brought to [**Hospital Unit Name 153**] for continued intubation, monitoring of volume
status and UOP post procedure.
.
On arrival to ICU, patient was intubated and sedated on
propofol. Vitals stable, oxygenating well, family at bedside.
Past Medical History:
-Large ascending aortic dissection in [**2160**] s/p Dacron graft
placement and St. Jude's valve placement (on coumadin goal INR
2.5-3.5)
-R perinephric bleed s/p IR embolization of R kidney ([**2165-12-15**])
-R renal mass
-Hypertension
-Hypercholesterolemia
-Mild chronic kidney disease (baseline Cr 1.1-1.3)
Social History:
married, has 3 children. occasional EtOH, denies tobacco
Family History:
Mother, father with hypertension, sister with CVA
Physical Exam:
VITALS ?????? 98.7, 165/49, 77
GENERAL - intubated, sedated
HEENT - PERRLA
NECK - supple, no thyromegaly, JVP=10
LUNGS - CTA anteriorly
HEART - +mechanical SEM in across precordium, no rubs
ABDOMEN - dressings over large right flank incision site, c/d/i,
soft, trace bowel sounds
EXTREMITIES - WWP, no LE edema
Brief Hospital Course:
Patient was admitted post-operatively to the [**Hospital Ward Name 332**] ICU under
Dr.[**Name (NI) 24219**] Urology service. He remained intubated overnight
due to the length of the case, but did well overnight, weaning
on vent settings appropriately and he was extubated without
difficulty on POD 1. His heparin anticoagulation was restarted
approximately 8 hours after surgery at 1 am on [**2166-2-28**]. On POD
1, his PTT ranged from 65.7-94.3. In late POD 1, early POD 2,
he was noted to have a decreasing hct, for which he received a
transfusion of 2u pRBCs. However, after transfusion, his hct
did not change. His UOP decreased and his creatinine increased
from 1.8 immediately postoperatively to 4.1 on early POD 2. Of
note, he was given two doses of lasix 40 mg IV on POD 1. A CT
scan of the abdomen/pelvis without contrast was performed, which
demonstrated a large R retroperitoneal hematoma. Heparin gtt
was stopped and the patient was transfused as necessary to keep
his hct > 25. He received a total of 7u of pRBCs, after which
his hct stabilized off anticoagulation.
Cardiology was consulted regarding the safety of stopping
anticoagulation with a St. [**Male First Name (un) 1525**] mechanical valve present.
They concluded that the risk of restarting anticoagulation would
clearly have to be weighed against the risk of bleeding, but
that 3-4 days off anticoagulation would not lead to excessive
risk. The patient's heparin was restarted in the evening of his
third day off anticoagulation, and the pt had no evidence of
bleeding for the rest of his hospital stay.
Renal was consulted regarding the patient's acute renal failure,
which was thought to be secondary to acute tubular necrosis as a
consequence of transient hypoperfusion of the remaining kidney
either intraoperatively or postoperatively during his bleeding
episode. The patient's creatinine peaked at 5.3 on [**2166-3-2**],
after which his urine output improved significantly and his
renal function began to improve, settling out at 1.8 on
[**Date Range **]. He did not require dialysis during this
hospitalization.
After heparin was restarted and the patient's hct was noted to
be stable with a therapeutic PTT, the pt was transferred from
the ICU to the floor. The remainder of his hospital course was
uncomplicated, and involved restarting coumadin to reach a
therapeutic INR of 2.5-3.5. This required coumadin doses of 7.5
mg PO qhs to eventually reach an INR of 2.5 upon [**Date Range **]. The
patient's primary care physician was [**Name (NI) 653**], who recommended
discharging the patient on his home coumadin dose (3.0) with a
plan to follow-up with the pt's PCP three days later for an INR
check and coumadin dose adjustment.
Of note, one day before [**Name (NI) **], the pt was noted to have
small openings in his R flank wound in its medialmost- and
lateralmost edges. This breakdown was probed, and was noted to
be purely superficial, < 1 cm in depth and approximately 1-2 cm
in width. Steri strips with benzoin were applied and dry gauze
was applied. The patient was asked to call Dr. [**First Name (STitle) **] if his
wound drainage worsened or if the wound opened up further.
Before he was [**First Name (STitle) **], new steri strips were applied to the
extent of his wound. He was discharged in stable condition,
voiding without difficulty, ambulating without difficulty, and
tolerating a regular diet. He will call Dr. [**First Name (STitle) **] for a
follow-up appointment.
Medications on Admission:
Home meds confirmed with family
-Fenofibrate 145 mg PO daily
-Carvedilol 50 mg PO bid
-Amlodipine 10 mg PO daily
-Lisinopril 5 mg PO daily
-Colchicine 0.6 mg PO daily
-Coumadin 3 mg PO daily
[**First Name (STitle) **] Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**2166-3-17**] for an INR check to
keep your INR between 2.5-3.5.
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take to prevent constipation while taking
percocet. [**Month (only) 116**] stop if not taking percocet.
Disp:*60 Capsule(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Carvedilol 12.5 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
7. Fenofibrate 150 mg Capsule Sig: One (1) Capsule PO once a
day.
[**Month (only) **] Disposition:
Home
[**Month (only) **] Diagnosis:
Right renal cell carcinoma
[**Month (only) **] Condition:
Stable
[**Month (only) **] Instructions:
-Do not lift anything heavier than a phone book (10 pounds)
until you are seen by your Urologist in follow-up.
-Do not drive or drink alcohol while taking narcotics.
-Your medications have changed. Please take your medications as
instructed in the [**Month (only) **] instructions sheet. Please avoid
all NSAIDs (motrin, advil, aleve, ibuprofen)
-Call your Urologist's office today to schedule a follow-up
appointment in 3 weeks AND if you have any questions.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or [**Month (only) **] from your incision, call your doctor or
go to the nearest ER.
-There are small areas of breakdown on the ends of your wounds.
Expect some mild drainage from these areas. If you notice that
the drainage is increasing or that the wounds are getting
larger, please call Dr. [**First Name (STitle) **] immediately.
-Take your original coumadin dose of 3 mg daily. Please
follow-up with your PCP on [**Name9 (PRE) 766**] [**2166-3-17**] for an INR check.
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to set up follow-up appointment and if you
have any urological questions.
Followup Instructions:
Please call Dr.[**Name (NI) 24219**] office to arrange a follow-up
appointment.
Please follow-up with your primary care physician on MONDAY
[**2166-3-17**] for an INR check. Your INR checks will need to be more
frequent in the first two weeks because your coumadin doses have
been different. You will resume your original coumadin dose of
3 mg daily
Completed by:[**2166-3-15**]
|
[
"998.32",
"285.1",
"189.0",
"584.5",
"403.10",
"V43.3",
"V58.61",
"998.12",
"E878.6",
"272.0",
"585.9",
"274.9",
"728.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"07.22",
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
2378, 5879
|
384, 426
|
8404, 8787
|
1976, 2027
|
5905, 8381
|
2042, 2355
|
287, 346
|
454, 1550
|
1572, 1885
|
1901, 1960
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,838
| 134,899
|
34654
|
Discharge summary
|
report
|
Admission Date: [**2100-8-19**] Discharge Date: [**2100-9-15**]
Date of Birth: [**2039-6-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
VFib arrest at gym
Major Surgical or Invasive Procedure:
[**2100-9-2**] CABG x6 (Lima->LAD, SVG->Diag/DLAD/Ramus/OM2/PDA)
[**2100-9-10**] AICD placement
History of Present Illness:
61M hx ?viral cardiomyopathy, EF 10%, with vfib arrest,
transferred to [**Location (un) **] and found to have 3vd with placement of
IABP, now transferred to [**Hospital1 18**] for possible CABG.
.
This AM, pt at gym working out as per his normal routine, found
unresponsive, reportedly found in vfib and shocked x1, EMS
reports suggest pt in NSR, then lost pulse in ambulance, CPR
initiated, intubation attempted without success. Transferrred
to [**Location (un) **], unresponsive upon arrival, intubated, taken to cath
lab. Meds used, integrillin, heparin, nitro gtts, found to have
3vd with inf wall akinesis, with significant sys dysf with EF
15%, given diuresis with 80mg lasix, aspirin PR, no report of
plavix administered, swan pulled. Concern that pt not moving 1
side of body initially at OSH, but then moved all extremities at
an undetermined point later in day, transferred to [**Hospital1 18**] for
CABG consideration.
.
Pt continued on heparin drip and AC ventilation while in CVICU,
given coreg with SBP drop from 140 to 90, a-line in place with
2pIVs. Initial vs at 20:00, bp 90/60, hr 80, ac fio250% ngt to
suction with yellow-green contents, heparin drip on, with
propofol. ECHO performed upon transfer, results not documented,
reportedly EF 10-15%. CKs flat, trop elevated at 0.16.
Past Medical History:
Cardiomyopathy - thought viral [**12-26**], diagnosed at [**Location (un) **], with
multiple readmissions for CHF exacerbations with signficant DOE
and LE edema in [**2096**]. ECHO then showed global dyskinesis with
EF 20%. Did show e/o asymptomatic VT in [**2096**] DC summary.
Tobacco abuse
Ethanol abuse
Allergies - treated with clarinex
Bronchitis
Social History:
Patient lives at home with wife, continues to work as an
engineer without issue. Significant tobacco hx, ~pack/d for
years. +etoh with 1-2 drinks per day, for "29 years" as per
wife. [**Name (NI) **] apparent IVDU reported. Exercises daily for the past
29 years, does not workout on treatmill, uses "machines" and
does Yoga 2x/d.
Family History:
Father died heart dz 61, mother at 89 of "natural causes."
Sister died from ovarian cancer. Son and daughter both
[**Name2 (NI) 79476**] well
Physical Exam:
Admission
VS: T99, BP 95/64, HR 80, AC fio2 50%, peep 5, tv 50
Gen: vent, ngt to suction, non-responsive, on propofol
HEENT: pupils responsive to lt bil
Neck: Supple with JVP 3cm above clavicle on R
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2, +S3, 4/6 SEM throughout, ?iabp
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge
VS t98.5 Bp 97/58 HR 80SR RR 20 O2sat 97%-RA
Gen
NAD
Neuro Alert, nonfocal exam
CV RRR, sternum stable-incision CDI
Pulm CTA-bilat
Abdm soft, NT/ND/+BS
Ext warm, no edema
Pertinent Results:
ADMISSION LABS:
[**2100-8-19**] 02:49PM BLOOD WBC-14.7* RBC-4.49* Hgb-14.9 Hct-42.1
MCV-94 MCH-33.1* MCHC-35.3* RDW-12.3 Plt Ct-259
[**2100-8-19**] 02:49PM BLOOD Plt Ct-259
[**2100-8-19**] 02:49PM BLOOD Glucose-149* UreaN-14 Creat-0.8 Na-134
K-3.9 Cl-100 HCO3-24 AnGap-14
[**2100-8-19**] 02:49PM BLOOD ALT-35 AST-42* LD(LDH)-286* CK(CPK)-118
AlkPhos-81 TotBili-0.6
[**2100-8-19**] 02:49PM BLOOD CK-MB-7 cTropnT-0.16*
[**2100-8-19**] 02:49PM BLOOD Albumin-3.9 Calcium-8.1* Phos-3.4 Mg-1.9
[**2100-8-19**] 09:11PM BLOOD TSH-0.48
[**2100-8-19**] 03:04PM BLOOD Type-ART pO2-331* pCO2-36 pH-7.46*
calTCO2-26 Base XS-2
[**2100-8-19**] 03:04PM BLOOD Lactate-2.2*
[**2100-8-20**] 01:25PM BLOOD Glucose-127*
[**2100-8-19**] 03:04PM BLOOD O2 Sat-99
[**2100-8-19**] 03:04PM BLOOD freeCa-1.05*
.
.
PERTINENT LABS/STUDIES:
EKG:
[**8-19**] leads strip EKG 6am - irregularly irregular, with
st-elevation v3, with marked st changes with depressions in lat
leads, elevations III and
avF, nl axis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 9217**] [**Hospital1 18**] [**Numeric Identifier 79477**]Portable TTE
(Complete) Done [**2100-9-7**] at 5:17:40 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2039-6-12**]
Age (years): 61 M Hgt (in): 67
BP (mm Hg): 99/61 Wgt (lb): 140
HR (bpm): 74 BSA (m2): 1.74 m2
Indication: Re-assess LVEF s/p CABG. Previous history of MI,
arrest.
ICD-9 Codes: 414.8, 424.0
Test Information
Date/Time: [**2100-9-7**] at 17:17 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West [**Hospital Ward Name 121**]
[**1-24**]
Contrast: None Tech Quality: Adequate
Tape #: 2008W052-1:30 Machine: Vivid [**6-28**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Peak Pulm Vein S: 0.3 m/s
Left Atrium - Peak Pulm Vein D: 0.5 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 20% to 25% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.5 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.13
Mitral Valve - E Wave deceleration time: 150 ms 140-250 ms
Findings
This study was compared to the prior study of [**2100-8-25**].
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Severely depressed LVEF. [Intrinsic LV systolic function likely
depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Eccentric
MR jet. Moderate (2+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its
severity may be underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 20-25 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. An eccentric,
posteriorly directed jet of moderate (2+) mitral regurgitation
is seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2100-8-25**],
findings are similar.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2100-9-7**] 17:54
[**Known lastname **],[**Known firstname 9217**] [**Age over 90 79478**] M 61 [**2039-6-12**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2100-9-3**]
10:07 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2100-9-3**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 79479**]
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
61 year old man s/p cabg and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
Final Report
HISTORY: CT removal, to evaluate for pneumothorax.
FINDINGS: In comparison with study of [**9-2**], all tubes have been
removed
except for a right IJ sheath. No evidence of pneumothorax. Some
residual
atelectatic changes on the left.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: FRI [**2100-9-3**] 11:33 AM
Imaging Lab
Brief Hospital Course:
[**2100-9-2**] Mr.[**Known lastname **] [**Last Name (Titles) 1834**] CABGx6 with Dr.[**First Name (STitle) **]. XCT=72",
CPB=117".Please refer to Dr[**Doctor First Name **] operative report for
further details.He was transferred to the CVICU intubated,
sedated and requiring pressors to augment cardiac output/index.
Mr.[**Known lastname **] was extubated and delined in a timely fashion. His
mental status remained confused, as it was preoperatively and
since his VF arrest. Narcotics were discontinued. No focal
deficit evident on exam. Psychiatry was consulted for
recommendations, as Mr.[**Known lastname **] remained in the CVICU for continued
confusion and supervision. Statin, Beta-blocker, and ACE-I was
started and optimized as BP tolerated.POD#3 he was transferred
to the SDU with a 1:1 sitter, for further telemetry and
recovery. EP was consulted re:EF=20% and history of cardiac
arrest preadmission, and the possible need for an AICD. [**9-10**]
Mr.[**Known lastname **] [**Last Name (Titles) 1834**] AICD placement, and it was interrogated the
next day. Due to the persistent state of agitation and
confusion, and need for supervision during recovery,medications
were titrated. His hemoglobin A1C was elevated at 6.7, and he
required sliding scale insulin coverage throughout his
hospitalization. It was suggested that he be started on an oral
hypoglycemic, but he refused stating that he would prefer to
discuss it with his PCP. [**Name10 (NameIs) **] POD# 13,he was cleared for
discharge to home with services. All follow-up appointments were
advised.
Medications on Admission:
Lisinopril 5mg qd
ASA 325mg qd
Coreg 3.125mg [**Hospital1 **]
Lasix 40mg [**Hospital1 **]
Clarinex qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months: may stop if not needed in [**2-23**] weeks.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 1 months: 1mg [**Hospital1 **] x 10 days then 1mg @HS x 20 days.
Disp:*40 Tablet(s)* Refills:*0*
7. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
9. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
s/p CABG x6 (Lima->LAD, SVG->Diag/DLAD/Ramus/OM2/PDA)
s/p cardiac arrest pre-op
cardiomyopathy
CHF
ETOH
bronchitis
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Keep wounds clean and dry, shower daily, no bathing or swimming.
Call for fevers, redness or drainage from wounds.
No lifting greater than 10 pounds for 10 weeks.
No driving for 4 weeks and must be off all narcotics.
Take all medications as prescribed.
Daily weights, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) **]
follow-up with PCP: [**Last Name (NamePattern4) **].[**Last Name (STitle) **] in [**12-23**] weeks [**Telephone/Fax (1) 40144**]
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2100-9-21**]
1:00
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2100-10-1**] 9:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2100-9-15**]
|
[
"305.01",
"428.0",
"414.01",
"425.4",
"427.31",
"307.9",
"401.9",
"490",
"518.81",
"V12.53",
"599.0",
"V45.82",
"305.1",
"041.19",
"428.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"89.49",
"39.61",
"96.6",
"96.72",
"36.14",
"00.51",
"97.44"
] |
icd9pcs
|
[
[
[]
]
] |
12368, 12431
|
9428, 11000
|
339, 439
|
12590, 12599
|
3487, 3487
|
13151, 13800
|
2520, 2664
|
11153, 12345
|
8904, 8944
|
12452, 12569
|
11026, 11130
|
12623, 13128
|
7328, 8864
|
2679, 3468
|
281, 301
|
8976, 9405
|
467, 1775
|
3504, 7279
|
1797, 2153
|
2169, 2504
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,149
| 119,051
|
25058
|
Discharge summary
|
report
|
Admission Date: [**2141-9-15**] Discharge Date: [**2141-9-17**]
Service: MEDICINE
Allergies:
Shellfish / Sulfa (Sulfonamides) / Penicillins / Levofloxacin
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
S/P cath for NSTEMI - 90% L Main Ostial Lesion stented. In CCU
[**12-21**] dementia, mod AS and close monitoring.
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement
History of Present Illness:
HPI: 85 yo F h/o unstable angina with multiple past admissions
to [**Hospital3 3583**], moderate AS, hypercholesterolemia, past
smoker, COPD, CRI, H/O TIA, Dementia, Anemia, AAA, GERD (? h/o
GIB) presents on Tx from [**Hospital3 **] where she presented for
Chest Pain and SOB from NH - found to have NSTEMI. On
presentation here, seen by CT surgery and poor [**Doctor First Name **] candidate,
so taken to cath here. Pt now s/p cath with stenting of 90%
ostial L Main lesion with resolution of ST changes post-cath.
Doing well.
Past Medical History:
HTN
hypercholesterolemia
CRI
COPD
Dementia
H/O TIA
?SSS
Anemia
GERD with ? h/o GIB
OA
AAA found incidentally on cath today
Social History:
50 pk-yr h/o tobacco - quit 5 yrs ago
Lives in [**Location **]. Husband died of MI at age 59.
Family History:
Non-contributory
Physical Exam:
V: AF, 142/57, 51, 18, 99%
G: Sleeping, NAD, arousable easily
H: Pupils reactive, NCAT, no LAD, transmitted murmur in carotids
C: RRR, III/VI SEM (cresc/decresc) at RUSB transmitted to LUSB.
No axillary murmur appreciated. No JVD.
L: Clear laterally and anteriorly
A: Soft, NT, No masses, decr BS
E: Groin with sheath in no bleeding, no hematoma, 2+ DP, 1+ PT
bilaterally. Good cap refill - L foot cooler than R (cath on R).
N: grossly non-focal
Pertinent Results:
Echo [**9-15**]:
Aortic Valve Area: *1.0 cm2 / EF 50%
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with focal hypokinesis of
the distal inferior wall. The remaining segments contract well.
[Intrinsic left ventricular systolic function may be more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is moderate
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. At least moderate
(2+) mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be quantified. There is no pericardial
effusion.
IMPRESSION: Moderate aortic valve stenosis. Regional left
ventricular systolic dysfunction c/w CAD.
..
Cath [**9-15**]:
COMMENTS:
1. Selective coronary angiography revealed a LEFT dominant
system with severe left main CAD. The vessels all had moderate
calcification. The LMCA was short and calcified. It had an
ostial 90% stenosis. The LAD had a 50% proximal stenosis and
appeared to have aneurysmal dilatation both before and after
this stenosis. The remainder of the LAD had mild luminal
irregularities only. The LCX had mild luminal irregularities
only. The RCA was non-dominat with no significant disease.
2. Hemodynamics revealed severely elevated left heart filling
pressures and moderately elevated right heart filling pressures.
There was mild pulmonary hypertension. The cardiac output and
index were preserved.
3. Assessment of the aortic valve revealed a 15-18mm Hg peak
aortic
gradient with a a valve area of 1.2cm2, consistent with moderate
aortic stenosis.
4. Left ventriculography was not performed.
5. Of note, there appeared to be an aneurysm in the abdominal
aorta
which meant that it was difficult to pass the J-wire up. A magic
torque wire was used. The aneurysm could well precluded IABP
use.
6. The patient's sheaths were sewn in place and she was taken
off the
table pending consideration of possible cardiac surgery. If she
is
refused this option, attempt to stent the LMCA may be done.
FINAL DIAGNOSIS:
1. Two vessel (left main) coronary artery disease.
2. Moderate aortic stenosis.
3. Mild mitral regurgitation.
4. Severe diastolic ventricular dysfunction.
5. Abdominal aortic aneurysm.
[**2141-9-15**] 11:00PM POTASSIUM-4.5
[**2141-9-15**] 11:00PM CK(CPK)-76
[**2141-9-15**] 11:00PM PLT COUNT-257
[**2141-9-15**] 06:19PM GLUCOSE-182* UREA N-20 CREAT-1.1 SODIUM-140
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
[**2141-9-15**] 06:19PM CK(CPK)-93
[**2141-9-15**] 06:19PM CK-MB-7 cTropnT-0.55*
[**2141-9-15**] 06:19PM CALCIUM-8.8 PHOSPHATE-3.5 MAGNESIUM-1.7
[**2141-9-15**] 06:19PM WBC-5.0 RBC-3.88* HGB-10.5* HCT-31.7* MCV-82
MCH-27.2 MCHC-33.2 RDW-14.8
[**2141-9-15**] 06:19PM PLT COUNT-261
[**2141-9-15**] 10:44AM TYPE-ART O2 FLOW-2 PO2-69* PCO2-39 PH-7.40
TOTAL CO2-25 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
Brief Hospital Course:
This 85 yo female was transferred from [**Hospital3 **] for
NSTEMI following at least one week history of chest pain. At
[**Hospital1 18**], patient underwent cardiac catheterization and had stent
placement of left main coronary artery. Of note, an AAA was
also found at the time of catheterization. Following stent
placement, the patient was started on aspirin and Plavix, as
well as 80mg atorvastatin, 12.5mg metoprolol, and 10mg
lisinopril. It is recommended that her blood pressure
medications be titrated for target BP of 125/75. The patient
also underwent a TTE, which revealed moderated aortic stenosis,
mild mitral regurgitation, regional left ventricular systolic
dysfunction consistent with CAD, 50% ejection fraction. The
patient did not exhibit any further EKG changes or chest pain
following stent placement. Cardiac enzymes trended down with a
peak CK of 93, 55 on day of discharge. The patient was
monitored on telemetry, noted to have some ectopy, electrolytes
were monitored without any need for replacement. The patient
was noted to have a history of anemia upon admission, and
required one unit of PRBCs to maintain a target hematocrit of
>30. The patient's daughter was [**Name (NI) 653**] prior to discharge to
discuss the need for follow-up with the patient's cardiologist
within 1-2 weeks. In addition, the patient may need to undergo
repeat catheterization in [**1-22**] months to evaluate for further
disease. In addition, the patient will need to have her
creatinine monitored due to her history of chronic renal
insufficiency, and a noted elevation in her creatinine thought
to be secondary to insult from catheterization dye. It is
recommended that the creatinine be rechecked no later than the
Tuesday following discharge. The patient maintained good urine
output throughout hospitalization, and did not require any IVF
as she was able to maintain adequate po intake.
The patient was continued on Zyprexa for her history of
dementia, and a sitter was provided when necessary to ensure
patient safety. The patient was also continued on her albuterol
inhaler PRN for her history of COPD and was maintained on a PPI
for GI protection, as well as subcutaneous heparin for DVT
prophylaxis. Following catheterization, the patient was
restarted on and tolerated well a low sodium, heart healthy
diet. In addition, the patient was evaluated by physical
therapy prior to discharge, it was recommended that patient
would benefit from PT at nursing home, with no acute issues
found. The patient's daughter was [**Name (NI) 653**] on the day of
discharge and informed of the follow-up that the patient would
require, and was agreeable to schedule the necessary
appointments.
Medications on Admission:
All: PCN, shellfish, PCN, sulfa, aleve, risperidol
On tx - lovenox, IV nitro, Lopressor 12.5 [**Hospital1 **]
also, zyprexa, fluoxetine, mirtazapine, lorazepam, albuterol INH
Discharge Medications:
1. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina.
12. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-20**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Increase as tolerated for goal blood pressure of
125/75.
Discharge Disposition:
Extended Care
Facility:
Evanswood Center for Older Adults - [**Location (un) 8072**]
Discharge Diagnosis:
NSTEMI with stent placement in left main coronary
Aortic Stenosis
COPD
Dementia
Anemia secondary to blood loss
Chronic renal insufficiency
Hypertension
AAA- found during cardiac cath
Discharge Condition:
Good- patient hemodynamically stable, chest pain free.
Discharge Instructions:
We have started you on a new medication called Plavix for your
heart disease, you must take this medication and an aspirin
every day. Please continue to take all of your medications as
instructed. Please return to the hospital if you develop chest
pain, shortness of breath, fever, or chills. You will need to
have your creatinine checked on Tuesday, and will need to
follow-up with Dr. [**Last Name (STitle) 5310**] and Dr. [**Last Name (STitle) 41415**] within the next two
weeks.
You should have your ACE inhibitor increase over the next few
months with a target blood pressure of 125/75.
Followup Instructions:
You will need to have your creatinine checked no later than
Tuesday to evaluate your renal function. In addition, you will
need to have follow-up with Dr. [**Last Name (STitle) 5310**] within one week.
Please call [**Telephone/Fax (1) 5315**] to schedule an appointment. Also,
please make an appointment with Dr. [**Last Name (STitle) 41415**] within the next two
weeks, call [**Telephone/Fax (1) 61767**].
Chest CT done at other hospital revealed nodules (8mm in RLL and
14mm in LLL) in your lungs, the significance of these is
unknown, and may need to be followed up with additional imaging.
Please discuss this with your primary care doctor. Because you
had a stent placed in your left main coronary artery, you should
discuss with your cardiologist about a repeat angiography within
3-6 months to ensure optimal blood flow.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
"593.9",
"280.0",
"414.01",
"V15.82",
"530.81",
"401.9",
"396.2",
"410.71",
"441.4",
"414.11",
"496",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.78",
"36.07",
"99.04",
"88.55",
"00.40",
"37.23",
"37.22",
"00.66",
"99.20",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
9221, 9308
|
4893, 7615
|
383, 430
|
9535, 9592
|
1767, 3983
|
10235, 11195
|
1265, 1284
|
7840, 9198
|
9329, 9514
|
7641, 7817
|
4000, 4870
|
9616, 10212
|
1299, 1748
|
228, 345
|
458, 990
|
1012, 1136
|
1152, 1249
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,168
| 183,563
|
18711+18740
|
Discharge summary
|
report+report
|
Admission Date: [**2125-7-2**] Discharge Date: [**2125-7-11**]
Date of Birth: [**2076-12-10**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old
gentleman who was working on a roof when he lost his balance
and fell off the roof scaffolding on the way down, ultimately
hitting the left side of his body on the ground. He said he
did not hit his head. There was no loss of consciousness.
He complained only of low back pain. There was no numbness
or weakness in the extremities after the fall.
He was seen at an outside hospital where a L1 burst fracture
was found with some retropulsion.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. C5-C6 discectomy in [**2119**].
2. He has had a tracheostomy.
3. Carpal tunnel bilaterally.
4. Bilateral degenerative joint disease of the knees.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: He takes Vicodin.
SOCIAL HISTORY: The patient is a four pack per day smoker
for 10 years. He drinks two six-packs of beer per week.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed blood pressure was 147/92, heart rate was 77,
respiratory rate was 16, and oxygen saturation was 99% on
room air. Temperature was 99.2. In general, the patient was
awake and alert. In no acute distress. [**Location (un) 2611**] Coma Scale
was 15. Head, eyes, ears, nose, and throat examination
revealed pupils were equal, round, and reactive to light.
Cranial nerves were intact. Neck examination revealed a
cervical collar was in place. The trachea was midline.
Chest was nontender with equal breath sounds. The abdomen
was soft and nontender. Extremity examination revealed 5/5
strength in all four extremities. Sensation was intact
throughout all four extremities. The pelvis was stable. His
rectal examination was guaiac-negative with normal tone. His
neurologic examination revealed the patient awake and
oriented. Cranial nerves II through XII were intact. Pupils
were 3 mm to 2mm. Extraocular movements were full. No pain
to palpation over his head. No otorrhea or rhinorrhea. No
neuropathic sign. Motor strength was [**4-23**] in both the upper
and lower extremities. He had normal sensation. Rectal tone
was reported, as previously reported by the trauma team. His
reflexes were one and symmetric throughout.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory data
revealed white blood cell count was 9.1, hematocrit was 43.4,
and platelet count was 224. Sodium was 136, potassium was
3.7, blood urea nitrogen was 13, and creatinine was 1.
Albumin was 4.2. Calcium was 9. AST was 29 and ALT was 18.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of his
lumbar region showed an L1 burst fracture with retropulsion
and multiple fragments.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to
the Intensive Care Unit where neurologic checks were
monitored very closely every one hour. He was fitted for
TLSO brace. Plain films were needed. A magnetic resonance
imaging of his spine for T12 through L1 serially were
recommended. He was placed on logroll precautions.
The magnetic resonance imaging of his lumbar spine showed a
compression fracture of L1 with retropulsion of the bone into
the canal was noted. There was evidence of canal stenosis
with approximately 50% of spinal canal compromised. There
was no definite evidence of abnormal signal in the spinous
process region. There was a left focal left-sided disc
protrusion at L3-L4 with compromise of the thecal sac.
The patient was monitored on [**7-3**] in the Intensive Care
Unit where his vital signs were stable. His hematocrit
remained at 40.9. He remained neurovascularly intact. He
was waiting for a TLSO brace, and he remained on logroll
precautions.
He was transferred to the floor on [**7-3**]. On [**7-4**], his
pain was under control. His motor strength in his lower
extremities were full. His sensation was intact. He
received upright films, and a brace, and a Physical Therapy
consultation. The patient had difficulty obtaining standing
films where he needed a significant amount of pain
medications. At that time, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1327**] did discuss
with the patient his inability to bear weight or ambulate,
and he did advise the patient to proceed with surgical
decompression and stabilization, and that would hopefully
early mobilization. It was discussed that he would have a
retroperitoneal L1 vertebrectomy with a T12 through L2 fusion
using a titanium cage and plate device. The risks, benefits,
and alternatives were discussed with the patient.
On [**7-7**], the patient did have a L1 vertebrectomy and T12
through L2 fusion using a titanium cage and plate device.
The patient tolerated the procedure well. He was monitored
overnight in the Intensive Care Unit, and he was given
propofol for sedation. He proceeded to chest x-ray
postoperatively, and it was within normal limits. He was
kept on the ventilator overnight. Also postoperatively, the
patient was started on Kefzol 1 g q.8h. The patient was
also on empiric coverage with levofloxacin 500 mg q.24h.
Postoperatively, his incision was clean, dry, and intact. On
[**7-7**], the propofol was discontinued, and the patient was
extubated. Postoperatively, the patient did have a chest
tube in place. On [**7-7**], his postoperative hematocrit was
28.6. He had an INR of 1. His [**Location (un) 1661**]-[**Location (un) 1662**] drain had put
out 80 cc. The patient was also on a Dilaudid
patient-controlled analgesia with good pain control and was
receiving Ativan as needed.
On [**7-8**], the patient was neurologically intact. He was
transferred to the surgical floor. His nasogastric tube was
discontinued. He had a brace in place. He started to
increase his activity using the brace. His chest x-ray on
[**7-8**] showed a slight increased patchy left retrocardiac
opacity on the left which was concerning for possible
pneumonia. Therefore, the patient was continued on Levaquin
for that. There was no pneumothorax noted. As mentioned, on
[**7-8**], the patient was moved to the regular surgical floor.
He was awake, alert, and oriented. His motor strength in his
lower extremities was [**4-23**] bilaterally. He was started on a
clear liquid diet and was seen by Physical Therapy. He also
was continued with his chest tube, which on [**7-9**] showed no
evidence of pneumothorax and a resolving opacity in the right
middle lung zone was improving. There was difficulty with
Occupational Therapy as the patient was refusing to do any
activity with them, and they agreed to come back and assist
him on [**7-10**].
On [**7-10**], the patient did work more with Physical Therapy
and Occupational Therapy. His Occupational Therapy was
discontinued. The patient was not interested in any help
with them. On [**7-10**], the patient did see Rheumatology for
bilateral foot pain for four days. He has a history of gout.
They made some recommendations for nonsteroidal
antiinflammatory drugs; however, given his postoperative
concerns, history of gastritis, that was not started. They
did recommend that if his symptoms worsened we could consider
prednisone or colchicine. Physical Therapy continued to work
with the patient.
On [**7-11**], Physical Therapy discontinued any acute need to
continue therapy with them. The patient had his TLSO brace
adjusted prior to discharge. The patient had a bilateral
lower extremity examination which was [**4-23**]. He was
neurologically intact.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to keep an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 1327**] in one month and to have x-rays prior to his
discharge.
2. The patient was to have his staples removed by [**2125-7-20**].
3. The patient was to keep his incision clean, dry, and
intact.
4. The patient was to follow up with the [**Hospital 2225**] Clinic
for an appointment regarding his toe pain.
MEDICATIONS ON DISCHARGE: The patient was given a
prescription for Percocet one to two tablets q.4h. for pain
(#30 dispensed).
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern4) 26792**]
MEDQUIST36
D: [**2125-7-27**] 14:25
T: [**2125-7-31**] 11:28
JOB#: [**Job Number 51296**]
Admission Date: [**2125-7-2**] Discharge Date: [**2125-7-11**]
Date of Birth: [**2076-12-10**] Sex: M
Service: NEUROSURGE
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
gentlemen who fell 12 feet from a roof. Past medical history
of C5-C6 discectomy, carpal tunnel, and bilateral
degenerative joint disease of the knees. Patient slipped off
a roof and fell 12 feet to scaffolding and then 5 feet to the
ground. He was transferred to [**Hospital **] Hospital with no
loss of consciousness, no head trauma, no memory loss. GCS
was 15. He was transferred to [**Hospital6 2018**] after CT of the L spine showed an L1 [**Last Name (un) 51356**] fracture
with retropulsion. Patient had no other injuries. CT showed
L1 [**Last Name (un) 51356**] fracture with retropulsion of multiple fragments.
He was admitted to the Trauma Intensive Care Unit. He was
put on a Solu-Medrol protocol.
PHYSICAL EXAMINATION: Temperature 98.6. Blood pressure
116/76. Heart rate 64. Oxygen saturation 95% on two liters.
He is alert and oriented times three, following commands,
conversant, moving all extremities. Pupils were 3 down to 2
mm. He had no head trauma. His neck was supple. Lungs were
clear to auscultation. Cardiovascular: Regular rate and
rhythm, no murmurs, rubs or gallops. Abdomen is soft,
nontender, nondistended. Neurological: Alert and oriented
times three. Cranial nerves II through XII are intact.
Sensation intact to light touch throughout. Motor strength
was [**4-23**] in all muscle groups. His deep tendon reflexes were
1+ at the knees, 0 at the ankles.
HOSPITAL COURSE: The patient was fitted for a TLSO brace.
The patient was out of bed in TLSO brace and had upright
x-rays done. Patient has been unable to stand up or bear
weight in order to obtain the upright radiograph secondary to
severe lower back pain. In view of his considerable pain and
inability to bear upright weight, patient will be taken to
the Operating Room for T12-L2 fusion and L1 vertebrectomy.
The patient tolerated the procedure well without
interoperative complications. Postoperative vital signs are
stable. He was afebrile. His motor strength was [**4-23**] in all
muscle groups. He was opening his eyes spontaneously.
He was transferred to the Intensive Care Unit secondary to
poor pulmonary status postoperatively. He remained
intubated postoperatively. He was sleep on sedation but
pulling legs up, spontaneously opening his eyes to
stimulation. Chest x-ray on [**7-7**] showed right middle lobe
opacity and atelectasis and a left retrocardiac opacity
secondary to atelectasis. He was transferred to the regular
floor on [**2125-7-8**]. On [**2125-7-8**], the patient was
alert and oriented times three. Strength was [**4-23**]. His brace
was in place. He was transferred to the regular floor. He
tolerated a regular diet. He remained stable. His
nasogastric tube was discontinued and he was started on clear
liquids. Physical Therapy evaluated him. He had
postoperative x-rays done on [**2125-7-10**]. Rheumatology was
consulted for the patient's complaints of gout and his ankle.
Patient's ankle films showed no fracture. Rheumatology
recommending restarting his gout medication. He remained
neurologically stable. He was then discharged on [**2125-7-11**] in stable condition with follow-up with Dr. [**Last Name (STitle) 1327**] in
one week for staple removal. His medications at the time of
discharge include:
DISCHARGE MEDICATIONS:
1. Famotidine 20 mg po q.d.
2. Nicotine 14 mg po q.d.
3. >.......<1-2 tablets po q. 4 hours prn for pain.
PATIENT'S CONDITION: Stable at the time of discharge.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2126-1-22**] 12:51
T: [**2126-1-22**] 14:00
JOB#: [**Job Number 51357**]
|
[
"518.0",
"E884.9",
"806.4",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"77.89",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
11918, 12351
|
8050, 8559
|
906, 925
|
10044, 11895
|
7610, 8023
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2831, 7577
|
9358, 10026
|
8588, 9335
|
655, 879
|
942, 2797
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,568
| 179,210
|
35008
|
Discharge summary
|
report
|
Admission Date: [**2141-10-11**] Discharge Date: [**2141-10-23**]
Date of Birth: [**2120-2-4**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Tachycardia/Hypertension/Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
21 y/o F, nursing student, with h/o head trauma in [**2133**] with
minor bleed, tonic clonic seizure, now off dilantin, IBD;
constipation predominant, and episodes of tachycardia,
hypertension, chest pain and palpitations, concerning for
autonomic dysfunction.
Pt was in her USOH until 12 days ago. She was on her clinicals
as a 3rd year nursing student on the Ob/Gyn [**Hospital1 **] when she
abruptly felt light-headed and as if she was about to faint.
Denies syncope or LOC, headache, vision changes. weakness,
numbness/paresthesias. Pt does note that she had a URI a day or
two prior to that day. She also notes that her OCP was changed
to a generic about 1 month ago.
.
The pt was initially admitted to [**Hospital6 28728**] Center
after presenting with diaphoresis and vision changes. CTA
Chest/Abdomen were unremarkable. CT Head was also unremarkable.
Patient was transferred to [**Hospital1 18**] for further management of these
episodes.
.
Patient reports that episodes are induced when she sits up, but
can occur at any position: lying or sitting. Her BP during these
episodes have been noted to be as high as 200/130 with HR 150's.
Dyspnea, chest tightness and palpitations typically accompany
these episodes. She denies ever having LOC, or
numbness/weakness. She underwent cardiac and pulmonary workups
which are negative to date including ROMI and negative CTA. TTE
with bubble study was normal. [**Doctor First Name **], ANCA, RF, alpha 1
antitrypsin, urine catecholamines, metanephrines, VMA, 5-HIAA,
cortisol pending at time of transfer. CT adomen had per prelim
report showed normal adrenal glands.
.
Past Medical History:
Traumatic Head Injury related to ice skating accident in [**2133**].
She had a generalized tonic-clonic seizure and was on Dilantin
for 2 months. No seizures since this event
Knee Surgery
? IBS - pt reports several year history of constipation
alternating with diarrhea. Underwent EGD this summer showing
gastritis.
Social History:
Nursing student, single with boyfriend, no tobacco/EtOH/illicit
drug use
Family History:
Mother - Breast Ca
Physical Exam:
General: Awake and alert, NAD
HEENT mucous membranes, no lesions
Neck Supple, no thyromegaly, no LAD, no bruits
Chest CTAB
CV nl s1/s2 mrg
ABD Soft, NT/ND, NABS
EXT no C/C/E, distal pulses full, warm and well perfused
Neuro: AA&Ox3, appropriate, normal affect Speech Fluent CN
II-XII intact, R pupil>L but both brisk and reactive, EOMI no
nystagmus, Motor: Normal bulk and tone, no tremor, rigidity
Strength: [**5-22**] throughout, Finger to nose and heel to shin intact
.
Orthostatics: The patient was sat up in bed - BP subsequently
dropped from 116/72 to 75/48 with HR change of 85 to 169. Pt had
convulsions with episode of hypotension but was alert and
communicative throughout episode.
ALL subsequent exams and episodes of tachycardia were associated
with Hypertension, not hypotension.
The paroxysmal episodes are consistent, typically begin with
chest discomfort or sometimes HA, followed by worsening chest
pain, tachycardia, back-arching/shaking, and hypertension.
Episodes resolve after several minutes or quickly after
administration of 0.5-1mg Morphine, and 0.5-1mg ativan. Pain and
tachycardia are the predominant features. Pt denies any anxiety
before or during episodes. Episodes occur whenever pt is
elevated to sitting position, but also occur when supine. They
have only occured during the day or evening, never at night when
the pt is sleeping. Pt is awake and alert during episodes, is
able to speak and mentate normally. She is able to request
medication. She is aware enough of her surrounds to look at the
monitor to see her own vital signs. During episodes, EKGs show
only reguarl sinus tachycardia. BPs observed as high as
170s/110s, but generally decrease quickly to 140s before
normalizing. Pessures are equal bilaterally. She appears
somewhat fatigued afterwards, but does not demonstrate
post-ictal symptoms of MS depression. Her neurologic exam is the
same before and after episodes.
Pertinent Results:
[**2141-10-11**] 06:11PM BLOOD WBC-6.7 RBC-4.14* Hgb-12.3 Hct-33.8*
MCV-82 MCH-29.7 MCHC-36.4* RDW-12.7 Plt Ct-302
[**2141-10-19**] 05:00AM BLOOD WBC-5.5 RBC-4.23 Hgb-13.0 Hct-34.6*
MCV-82 MCH-30.6 MCHC-37.5* RDW-13.1 Plt Ct-266
[**2141-10-11**] 08:16PM BLOOD Neuts-52.4 Lymphs-38.6 Monos-6.0 Eos-2.6
Baso-0.4
[**2141-10-11**] 06:11PM BLOOD PT-13.2 PTT-26.9 INR(PT)-1.1
[**2141-10-13**] 04:45AM BLOOD D-Dimer-169
[**2141-10-11**] 06:11PM BLOOD Glucose-111* UreaN-7 Creat-0.8 Na-139
K-4.2 Cl-107 HCO3-25 AnGap-11
[**2141-10-19**] 05:00AM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-138 K-4.2
Cl-103 HCO3-26 AnGap-13
[**2141-10-11**] 06:11PM BLOOD ALT-21 AST-22 LD(LDH)-111 CK(CPK)-44
AlkPhos-51 TotBili-0.2
[**2141-10-11**] 06:11PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-10-12**] 12:08PM BLOOD Lipase-42
[**2141-10-11**] 06:11PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.8 Mg-2.1
[**2141-10-19**] 05:00AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.0
[**2141-10-14**] 06:21AM BLOOD calTIBC-394 Ferritn-29 TRF-303
[**2141-10-12**] 12:08PM BLOOD Prolact-11 TSH-2.1
[**2141-10-12**] 08:04AM BLOOD Cortsol-33.6*
[**2141-10-12**] 12:08PM BLOOD HCG-<5
[**2141-10-12**] 12:08PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
EKG [**2141-10-11**]: Sinus tachycardia
Otherwise probably normal ECG, although unstable baseline makes
assessment
difficult. No previous tracing available for comparison
ECG09/30/08 Sinus tachycardia
Normal ECG except for rate Since previous tracing of [**2141-10-15**], no
significant change
CT-HEAD: [**2141-10-11**] NON-CONTRAST HEAD CT: There is no evidence of
infarction, hemorrhage, edema, shift of normally midline
structures or hydrocephalus. The density values of the brain
parenchyma are within normal limits. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. Imaged paranasal sinuses and
mastoid air cells are pneumatized and well aerated. Surrounding
soft tissues and osseous structures are unremarkable.
IMPRESSION: Normal head CT.
MRI-HEAD [**2141-10-13**]: IMPRESSION: Two areas of cystic appearance are
visualized on the right temporal region, possibly consistent
with arachnoid cysts, there is no evidence of abnormal
enhancement in this area or mass effect. Normal flow void signal
is identified in the major vascular structures. No other
abnormalities were detected intracranially.
MRA-NECK: [**2141-10-13**] MRA OF THE NECK. There is evidence of vascular
flow in both common carotids, the carotid bifurcations appear
unremarkable, the vertebrobasilar system is also normal. The
takeoff and appearance of the supraaortic branches is normal.
IMPRESSION: Normal MRA of the neck.
OCTREOTIDE([**2141-10-16**]); HISTORY: Question pheochromocytoma.
INTERPRETATION: Whole body images obtained at 6 hours and 24
hours SPECT images of the abdomen and pelvis obtained at 24
demonstrate no octreotide avid tissue. IMPRESSION: No octreotide
avid tumor localized.
BARRIUM SWALLOW IMPRESSION ([**2141-10-16**]): Normal barium swallow,
without evidence of esophageal dysmotility.
Brief Hospital Course:
21 year old female nursing student with hx traumatic brain
injury ([**2133**]) presenting with paroxysmal tachycardia and
hypertension and CP of unclear etiology.
The patient was initially admitted to the general medicine
floor, though was quickly transferred to the MICU after
triggering for episodes of hypertension, tachycardia and chest
pain. Throughout her course in the MICU the patient appeared to
be a well-appearing, healthy young woman, in no distress and
with completely stable vital signs between her paroxsymal
episodes of CP, Tachycardia, and HTN. Her course generally
consisted of daily exams, consultations and tests. Cardiology,
Neurology (Autonomics), and Psychiatry were all consulted and
contributed to the evaluation of the pt.
Her initial presenting complaint was orthostatic tachycardia and
HTN. Since admission the pt has had multiple episodes of CP,
tachycardia, and HTN, both when supine, and with elevation.
While the events can be precipitated by postural changes, they
do not require them. The episodes have a significant component
of chest pain, substernal, [**8-27**], nonradiating, that will slowly
decrease after episodes has resolved. Some episodes also are
preceeding by headache. Pt has been observed to develop signs of
pain before hemodynamic changes, though the two events happen
close in time. The differential includes Pheochromocytoma, POTS,
carcinoid, GBS w/ autonomic dysreflexia, psuedopheochromocytoma,
panic disorder and cardiac ischemia, PE, esophageal spasm, pain
from foreign body.
-PE: Pt had negative D-dimers both at [**Location (un) 1121**] and at [**Hospital1 18**].
She had a CT-PA negative for PE at [**Location (un) **].
-Pheochromocytoma was initially the leading diagnosis in this
patient, though as tests returned negative, it was felt that
this was unlikey the etiology of this patient's symptoms. Her
serum was negative for metanephrines at [**Hospital 1121**] Hospital,
where she was hospitalized prior to her transfer. Serum
metanephrines are the test with the highest specificity for
pheochromocytoma (approx 97%), 24h Urine metanephrines and
catecholamines have greater specificity, and were also normal
from [**Location (un) 1121**]. The 24H urine metanephrines and catecholamines
were repeated here and were again negative. Additional serum
fractionated metanephrines were also repeated here and again
returned negative. Additionally a CT-Abd at the [**Location (un) 1121**],
showed normal kidneys and adrenals and no other masses or
abnormalities.
-Carcinoid was considered in this patient, though felt to be
unlikely with a negative Octreotide scan at [**Hospital1 18**] and a
reassuring CT-abd at [**Location (un) 1121**], that showed normal
peri-appendiceal regions. There was a small density in the
appendix that was likely a fecolith. 24h Urine 5-HIAA was
negative.
-[**Last Name (un) 4584**] [**Location (un) **] syndrome was also considered, but the patient was
noted to have a normal EMG at the OSH and she had no further
evidence of ascending weakness or paralysis and remained
neurologically intact throughout her hospitalization.
-Intracranial process: This was ruled out as the patient had
negative Head CT x 2. MRI/MRA of head/neck was also normal (two
cystic structures, read as likely chronic arachnoid cysts) CT
neck and chest were unremarkable though an incidental single [**3-21**]
mm perifissural right middle lobe nodule, which was likely an
intrapulmonary lymph node was identified, and was determined to
be clinically insignificant with no further work up warranted.
-PE/Dissection/pulmonary/pleuritic process: negative CT-[**MD Number(3) 80047**], normal CXRs, normal sats, negative D-dimer x 2.
- CAD unlikely w/ stable CEs at multiple points, Normal EKGs,
and regular sinus tachycardia on EKGs during episodes.
- Cardiac structural/vascular mass: ECHO was normal.
- Seizure, unlikely, with normal LOC during episdoes, ability to
speak and mentate noramlly and response to morphine and no
typical post-ictal symptoms. Neurology was following this case
and was also in agreement that the patient's symptoms were
unlikely to be related to seizure activity.
- Lyme serologies - negative
- Psych consulted for consideration of psychiatric related
diagnoses after all testing is completed (e.g. panic disorder,
paroxysmal hypertension/pseudopheochromocytoma. Initial
impressions were that episodes were not panic disorders. The
patient refused formal evaluation by psychiatry, though did
agree that she would be amenable to seek counseling on an
outpatient basis.
- Autonomic dysfunction: Evaluated by neurology to have no
evidence of autonomic or baroreceptor dysfunction.
-Esophageal spasm, stricure, or foreign body. No evidence of
esophageal dysmotility or abnormalities were seen on barrium
swallow.
-Renal artery stenosis was evaluated for with a renal ultrasound
with dopplers, which was a normal study.
Given this patient's extensive work up with no identifiable
organic cause of her paroxysms of hypertension associated with
chest pain and tachycardia, the diagnosis of
pseudopheochromocytoma was considered and the patient was
started on beta blocker therapy and an SSRI for her symptoms.
The patient's blood pressure in between episodes would not
tolerate the addition of an alpha blocker. After starting
therapy with propranalol, the patient had marked improvement in
her symptoms, and had rare minor episodes of chest pain that
were not incapacitating. She was monitored over 48 hours with
no evidence or documentation of further episodes, and was noted
to be up and ambulating without difficulty or recurrences of her
episodes. Given the improvement in her symptoms, she was
advised to continue taking nadolol as an outpatient, given the
ease of once a day dosing, as well as citalopram. She was also
advised to continue ativan as an outpatient, but to slowly taper
it in the future if she continued to do well, without symptoms.
She was also instructed to follow up with her primary care
physican after discharge to monitor her symptoms.
Medications on Admission:
OCP daily
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety, chest pain.
Disp:*30 Tablet(s)* Refills:*2*
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ocella 3-0.03 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pseudopheochromocytoma
Secondary:
IBS
Discharge Condition:
Stable and improved.
Discharge Instructions:
You were admitted to the hospital with episodes of chest
discomfort, high blood pressure, and tachycardia. Blood work and
urine were sent for evaluation and you were diagnosed with
pseudopheochromocytoma. You were started on a beta blocker and
an SSRI and your symptoms improved. You have been cleared
medically for discharge home.
Medication changes (added):
- nadalol 20mg once per day
- citalopram 20mg
- tylenol 350-650mg
- ativan 0.5mg 1 tab as needed three times a day for
breakthrough pain/anxiety
Please return to the ED if your symptoms return and
significantly worsen, or you have a fever > 101.
Followup Instructions:
Please monitor your blood pressure at home. If your systolic
blood pressure is less than 90, avoid taking your next dose of
ativan or atenolol. If your heart rate is less than 50
beats/minute, please hold your next dose of atenolol. If you
experience any fainting, please contact your doctor.
Follow up with your primary care physician [**Last Name (NamePattern4) **] 3 wks.
Dr. [**Last Name (STitle) 73250**], on Thursday [**2141-11-9**] at 3:00pm ([**Telephone/Fax (1) 54195**])
Please keep all your previously scheduled appointments.
Completed by:[**2141-10-24**]
|
[
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
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14089, 14095
|
7453, 13520
|
314, 320
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14187, 14210
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4388, 5948
|
14867, 15440
|
2414, 2434
|
13580, 14066
|
14116, 14166
|
13546, 13557
|
14234, 14844
|
2449, 4369
|
239, 276
|
348, 1968
|
5957, 7430
|
1990, 2308
|
2324, 2398
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,299
| 151,048
|
21895
|
Discharge summary
|
report
|
Admission Date: [**2137-11-13**] Discharge Date: [**2137-11-20**]
Date of Birth: [**2072-2-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Internal Cardiac Defibrillator Placement
Electrophysiology study
Endotracheal intubation
History of Present Illness:
65 y/o M w/ CAD s/p DES to LCx [**9-7**] and recent [**9-/2137**] admission
for lateral NSTEMI medically managed, HTN, DM2, HL, and 50 pack
year smoking history, transfered from OSH s/p cardiac arrest.
Per OSH reports, arrest was witnessed by a friend who performed
CPR until EMS arrived. EMS arrived on scene within 10 minutes,
and per EMS report, pt was pulseless and apneic on kitchen
floor. CPR was administered, pt was noted to be in V-fib, was
shocked 3 times, and then found to be in asystole so he was
intubated in the field, given Epi and Atropine and started on
amiodarone drip + 300mg IV bolus. CPR was continued until
arrival to OSH where BP found to be 85/palp and sinus tachy 110.
At OSH, EKG showed diffuse ST depressions (V2, V3, V4, V5, V6,
Lead I along with ST elevation in aVR. Pt was started on heparin
drip. Prior to transfer, BP 160/87, HR 90s on assist control
vent with TV 600, PEEP 4, FiO2 100%.
.
Pt was tranferd to [**Hospital1 18**] where he underwent urgent cardiac cath.
Cardiac Cath revealed patent coronaries, preserved LV function,
markedly elevated filling pressures, pulmonary HTN. They
recommended CTA to rule out PE and echo.
.
Unable to obtain ROS since pt is intubated and sedated ,
Past Medical History:
1. CARDIAC RISK FACTORS: Tobacco use, DM2, Dyslipidemia,
Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:
-> [**9-7**]: One vessel coronary artery disease of LCx with 60%
stenosis s/p Cypher DES, moderate left ventricular diastolic
dysfunction.
-> [**6-8**]: Coronary arteries are normal, mild diastolic
ventricular dysfunction.
-->[**9-13**]: Had lateral NSTEMI with peak trop 0.5, cathed showing
30% Ostial RCA and 40% Md LAD with elevated right heart sided
filling pressure, normal LV size, EF 52%, anterolateral
hypokinesis. Pt was medically managed.
Social History:
Lives alone in [**Location (un) **] MA, retired police officer
-Tobacco history: stopped 5mo ago, 50pack yr history
-ETOH: 4 beers/daily, no hx of withdrawal or seizures
-Illicit drugs: none
Family History:
Father deceased 70s of MI, mother deceased brain tumor.
Physical Exam:
Admission Exam:
VS: HR 85, BP 112/82, CMV mode 550 TV, RR 20, 50% FiO2, 100% O2
sat.
GENERAL: intubated, sedated, comfortable
NECK: Supple with JVP of 7 cm.
CARDIAC: RRR, no m/r/g
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No pedal edema, no calf tenderness
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Discharge exam:
Gen: NAD
HEENT: NC/AT
CV: S1, S2, no murmurs auscultated
RESP: CTAB
ABD: Soft, non-tender, BS +
EXTR: No edema, radial/pedal pulses 2+
Pertinent Results:
Cardiac cath: [**2137-11-13**]
FINAL DIAGNOSIS:
1. Normal coronary arteries.
2. Low-normal cardiac output with markedly elevated
biventricular
filling pressures.
3. No pulmonary embolus on manual pulmonary artery angiography.
4. Preserved LV function and no aortic dissection on LV-gram.
.
CT head without contrast: [**2137-11-13**]
FINDINGS: There is no evidence of hemorrhage, edema, mass effect
or
infarction. The ventricles and sulci are normal in size and in
configuration. The mastoid air cells are clear. There is
circumferential mucosal thickening as well as inspissated
secretions seen in the sphenoid sinus, ethmoidal air cells
bilaterally and in the imaged portions of the maxillary sinuses.
The frontal sinuses are hypoplastic.
IMPRESSION:
1. No acute intracranial abnormality.
2. Bilateral paranasal sinus disease as above.
.
Echo: [**2137-11-14**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. There is mild regional left ventricular
systolic dysfunction with severe inferior/inferolateral
hypokinesis. The right ventricular cavity is dilated with
depressed free wall contractility. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-5**]+) mitral regurgitation
is seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CTA chest: [**2137-11-15**]
IMPRESSION: No evidence of pulmonary embolism. No indirect signs
of PE.
Bilateral dependent atelectasis. Bilateral basal right more than
left
additional parenchymal opacities which could be caused by
aspiration or early infection.
.
CT C-spine: [**2137-11-15**]
FINDINGS: There is no fracture or traumatic malalignment. The
craniocervical junction is intact. There is no prevertebral soft
tissue swelling, but note is made that the patient is intubated.
There are severe extensive multilevel degenerative changes
throughout the
cervical spine, as described below.
At C2-C3, there are mild degenerative changes with no spinal
canal stenosis or neural foraminal narrowing.
At C3-C4, there are posterior osteophyte formation and bilateral
facet
hypertrophy. No spinal canal stenosis is noted. There is mild
bilateral
neural foraminal narrowing, right more than left.
At C4-C5, there is a large posterior osteophyte formation. There
is moderate spinal canal stenosis. Bilateral facet hypertrophy
is noted with mild-to- moderate neural foraminal narrowing.
At C5-C6, there is large posterior osteophyte formation with
possible
concomitant calcification of the posterior longitudinal ligament
(2:51 and 401B:22), which is causing severe spinal canal
stenosis and indentation of the thecal sac. Bilateral facet
hypertrophy is noted with bilateral mild neural foraminal
narrowing.
At C6-C7, there is posterior osteophyte formation and facet
hypertrophy
bilaterally. Mild-to-moderate spinal canal narrowing is noted.
There is
moderate neural foraminal narrowing on the left. There is no
significant
neural foraminal narrowing on the right.
IMPRESSION:
1. No fracture or malalignment.
2. Multilevel extensive degenerative changes throughout the
cervical spine, which is more severe at C5-C6 with severe spinal
canal narrowing which is indenting the thecal sac.
.
Cardiac and chest MRI [**2137-11-18**]
Findings:
Structure and Function
There was normal epicardial fat distribution. The myocardium
appeared to have homogenous signal intensity. The pericardial
thickness was normal. There were no pericardial or pleural
effusions. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal. The left atrial AP dimension was mildly
enlarged. The right and left atrial lengths in the 4-chamber
view were mildly enlarged. The coronary sinus diameter was
normal.
The left ventricular end-diastolic dimension index was normal.
The end-
diastolic volume index was normal. The calculated left
ventricular ejection fraction was normal at 58% with normal
global systolic function. There was borderline
inferior/inferolateral wall hypokinesis. Cannot exclude mild
hypokinesis at the junction of the mid anterior septum and
anterior wall. The anteroseptal and inferolateral wall
thicknesses were both mildly increased. The left ventricular
mass index was normal. The right ventricular end- diastolic
volume index was normal. The calculated right ventricular
ejection fraction was normal at 61%, with normal free wall
motion. The aortic valve was tri-leaflet with normal valve area.
Quantitative Flow
There was no significant intra-cardiac shunt. Aortic flow
demonstrated mild aortic regurgitation. The calculated mitral
valve regurgitant fraction was consistent with trace mitral
regurgitation. The resultant effective forward LVEF was normal
at 57%. The right ventricular stroke volume and pulmonic flow
demonstrated no significant pulmonic or tricuspid regurgitation.
Myocardial Fibrosis and Edema
Enhancement was seen in the PSIR SENSE imaging in the mid
anterior/anteroseptal wall of the left ventricle, extending to
>50% of the thickness of the myocardium. It is distributed from
the subendocardial layer to the mid wall. As well, there is a
small focus of subendocardial enhancement in the mid lateral
wall.
Non-Cardiac Findings
Bright linearly oriented foci on STIR images, most probably
representing an artifact. Vague focus of slightly increased
signal intensity on multiple sequences along major fissure on
the right, corresponding to previously seen consolidation in
right middle lobe. Overall improvement of collapse of the lower
lobes bilaterally.
Impression:
1. Normal left ventricular cavity size with normal global left
ventricular systolic function, with borderline hypokinesis in
the inferior/inferolateral wall. Cannot exclude focal mild
hypokinesis at the junction of the mid anterior/anteroseptal
segment. The LVEF was normal at 58%. The effective forward LVEF
was normal at 57%. There is CMR evidence suggestive of prior
myocardial scarring/injury or myocarditis in the mid
anterior/anteroseptum and mid lateral walls.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 57%.
3. Mild aortic regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Mild biatrial enlargement.
6. A note is made of bilateral lower lobe atelectasis of the
lungs, improved since prior chest CT.
.
Admission labs:
[**2137-11-13**] 12:39PM WBC-16.7*# RBC-4.35* HGB-13.5* HCT-40.5
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.1
[**2137-11-13**] 12:39PM NEUTS-91.4* LYMPHS-3.9* MONOS-4.3 EOS-0.1
BASOS-0.3
[**2137-11-13**] 12:39PM TRIGLYCER-67 HDL CHOL-60 CHOL/HDL-2.8
LDL(CALC)-93
[**2137-11-13**] 12:39PM CALCIUM-8.5 PHOSPHATE-1.9*# MAGNESIUM-1.8
CHOLEST-166
[**2137-11-13**] 12:39PM CK-MB-19* MB INDX-5.8 cTropnT-1.03*
[**2137-11-13**] 12:39PM ALT(SGPT)-50* AST(SGOT)-53* CK(CPK)-329* ALK
PHOS-54 TOT BILI-0.6
[**2137-11-13**] 12:39PM GLUCOSE-181* UREA N-20 CREAT-1.2 SODIUM-138
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
[**2137-11-13**] 10:19AM TYPE-ART RATES-16/20 TIDAL VOL-500 PEEP-5
PO2-346* PCO2-38 PH-7.34* TOTAL CO2-21 BASE XS--4
INTUBATED-INTUBATED
[**2137-11-13**] 10:19AM GLUCOSE-244* LACTATE-2.8* K+-4.3
[**2137-11-13**] 10:19AM HGB-13.9* calcHCT-42 O2 SAT-99
.
Brief Hospital Course:
The patient is a 65 yo man with CAD, DM2, HTN, HLD, admitted to
the CCU for cardiac arrest s/p cardiac cath revealing patent
coronaries and who then underwent Arctic Sun cooling protocol.
.
# Cardiac Arrest: Pt transferred from OSH following VF and
asystole arrest. Patient had unremarkable Cardiac Cath revealing
patent coronaries. Echo showed inferolateral hypokinesis with EF
45%. Pt underwent arctic cooling protocol and was rewarmed
without complication. Head CT negative for intracranial bleed;
CTPA showed no acute PE. Imaging CT of C-spine showed no
malalignment but did show degenrative changes and some narrowing
in the C5-C6 area. Etiology of cardiac arrest was unclear. EP
was consulted. EP study showed a small scar near the mitral
valve, but no inducible areas. Cardiac MRI did not elucidate a
specific cause for the arrhythmia. The pateint was then sent for
the placement of an ICD, which went without complication.
.
# CORONARIES: History of CAD (DES to Left Circ in [**2131**], recent
[**9-/2137**] admission for NSTEMI treated medically with unremarkable
cardiac cath) who was admitted for VF arrest. OSH EKG revealed
diffuse ST depressions; however, Cardiac cath revealed patent
coronaries and no intervention was performed. Pt was continued
on Plavix 75mg daily, metoprolol 50mg [**Hospital1 **], atorvastatin, ASA for
medical management of CAD. The patient will need to remain on
Plavix until 9/[**2138**]. During his hospitalization, his metoprolol
was increased with 100 mg [**Hospital1 **]. He was also started on an ACE
inhibitor, lisinopril, with titration upward to 40mg by
discharge.
.
# PUMP: Echo revealed-inferolateral hypokinesis with EF 45%. RV
dilated and decreased free wall contractility. Cardiac MRI
showed an effective LVEF of 57%. There is CMR evidence
suggestive of probable prior myocardial scarring/injury or
myocarditis in the mid anterior/anteroseptum and mid lateral
walls.
.
# DM2: During his hospitalization, we held home metformin 500mg
[**Hospital1 **] and gave ISS. Blood sugars well controlled.
.
# HLD: Continued atorvastatin 80mg daily.
.
# HTN: Patient was discharged on metoprolol 100mg [**Hospital1 **] and
lisinopril 40mg QD, which were controlling his blood pressure.
.
# Possible pneumonia vs. aspiration pneumonitis: After the
patient's CT chest showed an area concerning for possible
infiltrate, the patient received a five-day course of
levofloxacin and flagyl. The patient did have a day in which he
complained of cough, but it was unclear if the cough was
secondary to GERD symptoms or was respiratory in nature. The
patient did not experience fever, and his WBC count never
increased. Nonetheless, his cardiac MRI did show improvement in
the area of concern in his lungs.
.
# Hematuria: The patient experienced hematuria following the
placement and removal of his Foley catheter. A urinalysis and
urine culture were not suggestive of infection. His hematuria
resolved one day after removal of Foley, suggesting he had
trauma from Foley.
Medications on Admission:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a da
4. Nitroglycerin 0.3 mg Tablet, Sublingual
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold if lightheaded/dizzy.
6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
7. Crestor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Medications:
1. metoprolol succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total of 2 doses as directed as
needed for chest pain.
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Crestor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. Zantac 150 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for post-ICD for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
11. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Ventricular Fibrillation Arrest
Aspiration Pneumonitis
Hematuria
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a cardiac arrest which means your heart stopped and you
needed CPR and defibrillation to get it going again. You were
transferred here for treatment. You did not have any blockages
in your coronary arteries and you underwent cooling to help your
brain recover from the event. You received antibiotics for a
pneumonia. You underwent a heart MRI and an electrophysiology
study that showed almost normal heart function and some scarring
from your prior heart attacks. We were not able to induce any
irregular rhythms with the EP study.
.
We made the following changes to your medicines:
1. Increase your Metoprolol Succinate to 200 mg daily
2. Decrease aspirin to 81mg
3. Continue to take Plavix (clopidogrel) every day until at
least 9/[**2138**]. Do not stop taking Plavix unless your cardiologist
tells you it is OK.
4. Stop taking Omeprazole, take Zantac or Ranitidine instead for
your heartburn
5. Take Cephalexin, an antibiotic to prevent an infection at the
ICD site
6. Take cough syrup with codeine to treat your cough as needed.
7. Take Tylenol as needed for the chest pain when you cough.
.
See the attached information sheet regarding activity
restrictions after an ICD placement. Please call Dr. [**Last Name (STitle) **]
if the ICD fires.
Followup Instructions:
Name: [**Last Name (LF) 11493**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] MD
Address: [**Apartment Address(1) 28703**], [**Location (un) **],[**Numeric Identifier 28704**]
Phone: [**Telephone/Fax (1) 11650**]
When: Wednesday, [**12-4**], 1:45PM
Department: CARDIAC SERVICES
When: FRIDAY [**2138-1-10**] at 1 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2137-11-25**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"867.0",
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"272.4",
"427.5",
"507.0",
"348.30",
"427.41",
"414.01",
"250.00",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.22",
"96.71",
"37.26",
"88.56",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
15673, 15741
|
10908, 13913
|
332, 423
|
15874, 15874
|
3344, 3375
|
17306, 18143
|
2514, 2572
|
14520, 15650
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15762, 15853
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13939, 14497
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16025, 17283
|
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|
3189, 3325
|
278, 294
|
451, 1676
|
10004, 10885
|
15889, 16001
|
1698, 1768
|
2305, 2498
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,157
| 192,858
|
42997+58576
|
Discharge summary
|
report+addendum
|
Admission Date: [**2137-10-22**] Discharge Date: [**2137-10-28**]
Date of Birth: [**2105-4-12**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old
white male with a chief complaint of increasing fatigue with
severe exertion on exercise. The patient has a congenital
bicuspid aortic valve diagnosed years ago and has noticed
increased fatigue when exercising heavily. He did not
complain of any chest pain, chest pressure or shortness of
breath when seen on [**10-16**] in the PAT.
Cardiac echocardiogram done on TTE showed an ejection
fraction of 55%, bicuspid AV valve with 1.9 cm2 area, mild
global hypokinesis with 1+ mitral regurgitation, moderate
left ventricular hypertrophy, 3+ aortic insufficiency, mild
aortic stenosis, and dilated left ventricle on [**2137-10-13**].
PAST SURGICAL HISTORY: 1. Excision of facial cyst, right
neck. 2. Drainage of prostate abscess. 3. Tonsillectomy.
4. Right orbital fracture with plate.
PAST MEDICAL HISTORY: Juvenile rheumatoid arthritis,
asymptomatic. H. pylori three months prior to admission.
Depression. Remote OxyContin/Cocaine abuse. Current
marijuana use, frequently. Old nasal fracture.
MEDICATIONS ON ADMISSION: ................. 450 q.d., Prozac
40 q.d., Propecia q.d., Vitamin B q.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
Last dental exam prior to admission was dental extraction on
[**2137-10-11**].
FAMILY HISTORY: Father who passed away of cirrhosis at age
66. Mother is alive and healthy at age 66.
SOCIAL HISTORY: PT caterer. He quit tobacco 11 years ago.
The patient lives with mother and sister. The patient had
prior alcohol abuse; he has been sober for three years.
Positive prior use of cocaine; he has been sober for four
years. Positive marijuana use,five times a week.
REVIEW OF SYSTEMS: General: The patient had some decrease
in weight on admission with H. pylori, at about 13 lbs over
the past few months. The patient was a very active athlete.
Negative for skin lesions at this time. HEENT: Disposable
contacts. [**Name (NI) **] nasal fracture. Respiratory: The patient
denied asthma and pneumonia, chronic obstructive pulmonary
disease, and shortness of breath. Cardiovascular: No
palpitations. No syncope. No paroxysmal nocturnal dyspnea.
No congestive heart failure. GI: Positive for H. pylori.
Negative for nausea, vomiting or diarrhea. Negative for
melena. Negative for gallbladder or liver disease. GU:
Negative for renal disease or calculi. Remote prostate
abscess. Musculoskeletal: Left ankle fracture. Right arm
fracture. Right wrist fracture. Positive for peripheral
vascular disease. Negative for claudication. Neurological:
Negative for transient ischemic attack or cerebrovascular
accident. Psychiatric: Positive for depression. Endocrine:
Negative for diabetes mellitus. Negative bleeding disorders.
PHYSICAL EXAMINATION: Vital signs: On admission the patient
was afebrile, heart rate 67 and regular, blood pressure
148/52, 6 ft 4 in tall, weight 225 lbs. General: The
patient had a very fit, athletic build. Skin: No obvious
disease or lesions. HEENT: Pupils equal, round and reactive
to light. Extraocular movements intact. Nonicteric. Not
injected. Neck: Without jugular venous distention. Murmur
radiates to bilateral carotids. He had a healed cyst scar.
Chest: Clear to auscultation bilaterally. Heart: S1 and
S2. Regular, rate and rhythm. He had a three out of six
systolic murmur with diastolic component. Abdomen: Soft,
nontender, nondistended. He had hypoactive bowel sounds.
Negative hepatosplenomegaly or CVA tenderness. Extremities:
Warm and well perfused without clubbing, cyanosis, or edema.
No varicosities noted. Neurological: Cranial nerves II-XII
grossly intact. Nonfocal. Excellent strength in all four
extremities. Pulses: 2+ bilaterally throughout femoral,
dorsalis pedis, posterior tibial and radial. Carotid bruit
murmur radiated to bilateral carotids heard.
LABORATORY DATA: Electrocardiogram showed left ventricular
hypertrophy, sinus rhythm at 51 beats per minute, nonspecific
ST/T changes.
HOSPITAL COURSE: The patient was prepped for aortic valve
replacement on [**2137-10-21**]. Prior to AVR, the patient
had a bronchoscopy for left mainstem thick mucosal secretions
which were occluded and aspirated.
The patient was taken to the operating room on [**2137-10-22**], for limited access aortic valve replacement with a 27
mm [**Last Name (un) 3843**]-[**Doctor First Name 7624**] bovine prosthesis utilizing
cardiopulmonary bypass.
The patient was taken to the operating room with a
preoperative diagnosis of 1) progressive aortic
insufficiency, 2) new left ventricular dilatation, and 3)
progressive fatigue.
Findings intraoperatively showed a congenitally bicuspid
aortic valve with fusion of the right and noncoronary cusps.
The aorta was not enlarged and was quite thin-walled and
elastic. TEE intraoperatively showed excellent
biventricular function with a well-seated, well-functioning
prosthesis after replacement.
The patient did very well postoperatively and was transferred
to the unit as mentioned before. He was extubated on
postoperative day #1.
At that time, the patient's hematocrit was 30.4; however, the
patient had an acute hematocrit drop on postoperative day #2
to 19 with a concurrent pneumothorax seen on chest x-ray.
The patient maintained saturations at 98% on room air,
however, was kept on oxygen for prophylactic therapy, and
chest tube was elected not to be placed because of the
patient's clinical and stable status. The patient was also
elected not to be transfused secondary to the fact that the
patient was clinically asymptomatic and ambulating on the
floor. Hematocrit and chest x-rays were taken daily and
monitored closely.
On postoperative day #3, the patient's hematocrit was 18.4,
and he was started on Vitamin C and Iron. Chest x-ray showed
resolving pneumothorax.
On postoperative day #4, the patient was transfused 3 U of
blood and continued to have oxygen saturations at 98% on room
air.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 10197**]
MEDQUIST36
D: [**2137-10-28**] 13:39
T: [**2137-10-28**] 13:42
JOB#: [**Job Number 92804**]
Name: [**Known lastname **], [**Known firstname 33**] Unit No: [**Numeric Identifier 14596**]
Admission Date: [**2137-10-22**] Discharge Date: [**2137-10-28**]
Date of Birth: [**2105-4-12**] Sex: M
Service:
Patient on postoperative day five was transfused initially 2
units of blood with a hematocrit rise to 22.8, then one more
unit with a hematocrit rise of 25.5 and patient remained
stable with a hematocrit of 25.5, and was discharged on
postoperative day #6 without event with a chest x-ray that
showed resolving pneumothoraces with still small apical
pneumothoraces.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg tablet one p.o. q.d.
2. Zantac 150 mg tablet one p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Lopressor 12.5 mg p.o. b.i.d.
5. Paxil 40 mg p.o. q.d.
6. Nefazodone 150 mg three tablets p.o. q.d.
7. Percocet 1-2 tablets p.o. q.4h. as needed for pain.
8. Milk of magnesia.
9. Ibuprofen 400 mg one p.o. q.6h. prn for pain.
10. Iron 325 mg tablet one p.o. q.d.
11. Vitamin C one tablet p.o. b.i.d.
DISCHARGE DIAGNOSES:
1. Juvenile rheumatoid arthritis.
2. Helicobacter pylori.
3. Depression.
4. Remote drug abuse.
5. Congenital bicuspid aortic valve with ASAI.
6. Status post limited access aortic valve replacement with
27 mm [**Last Name (un) 8522**]-[**Doctor Last Name **] Bovine prosthesis utilizing
cardiopulmonary bypass.
DISCHARGE STATUS: Home.
DISCHARGE CONDITION: Good.
DISCHARGE INSTRUCTIONS: The patient was instructed to call
doctor with temperature greater than 101.4 or if patient
experienced any nausea, vomiting, or dizziness. Patient is
also instructed to call if he experienced any redness,
swelling, drainage around the incision site, and to followup
with Dr. [**Last Name (STitle) 14597**], who is his primary care physician [**Last Name (NamePattern4) **] [**2-7**]
weeks, cardiologist in [**3-11**] weeks, who is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11634**] and
Dr. [**Last Name (STitle) **] Cardiothoracic Surgeon on one month at the number
[**Telephone/Fax (1) 1477**].
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern4) 14598**]
MEDQUIST36
D: [**2137-10-28**] 14:10
T: [**2137-10-28**] 14:11
JOB#: [**Job Number 14599**]
|
[
"041.86",
"934.1",
"429.3",
"780.79",
"512.1",
"285.9",
"424.1",
"790.01",
"746.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"88.72",
"96.05",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7834, 7841
|
1461, 1549
|
7475, 7812
|
7043, 7454
|
1251, 1444
|
4180, 7020
|
7866, 8767
|
873, 1009
|
2934, 4162
|
1853, 2911
|
186, 849
|
1032, 1224
|
1566, 1833
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,025
| 143,825
|
26049
|
Discharge summary
|
report
|
Admission Date: [**2131-5-10**] Discharge Date: [**2131-5-19**]
Date of Birth: [**2054-10-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Hayfever
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
elective admission for surgery
Major Surgical or Invasive Procedure:
[**2131-5-10**] Bifrontal craniotomy for resection,Removal of metastatic
lesion from the cribriform plate, posterior ethmoidal cells and
paranasal sinus, exenteration of frontal sinus with
cranialization, pericranial graft with vascular pedicleized
flap, primary repair of skull base CSF leak.
6. Microscopic dissection.
7. Lumbar drain placement.
History of Present Illness:
The patient is a 76-year-old who is well known to me from
previous hospital visit and extensive counseling. The patient is
a 76-year-old retired physician who was referred by Dr.
[**Last Name (STitle) 1837**] for a recurrent atypical melanoma that has
metastasized to the paranasal sinus. The patient has had
previous facial resection, fascia reconstruction, radiation
therapy. He now returns with progressive obstruction of airway
and imaging revealing an extensive metastasizing tumor growing
in the paranasal sinus. Since the lesion has eroded the frontal
skull base and filled the paranasal sinus, a surgical removal is
the treatment of choice. The patient was extensively counseled.
The patient
was then consented. The patient was taken electively to the
operating room.
Past Medical History:
R nephrectomy (metanephric adenoma '[**22**]),BPH s/p TURP '[**99**],
diverticulitis s/p colectomy '[**26**] c/b post-op leak/pancreatitis,
s/p rsxn desmoplastic melanoma [**Last Name (LF) 50847**], [**First Name3 (LF) **] fever @7yr,
thyphoid fever '[**89**], s/p Rt parotidectomy '[**91**], HTN
Social History:
Retired physician, [**Name10 (NameIs) 64683**] lives in [**Location 64684**], NY with wife
Family History:
non-contributory
Physical Exam:
On Discharge:
Alert, oriented. Pupils equally round and reactive to light.
Full motor strength in upper and lower extremities. Sensation
grossly intact.
Pertinent Results:
CT [**2131-5-14**]:
FINDINGS: Patient is status post bifrontal craniotomy for
extirpation of
extensive metastatic (melanoma) involvement of the cribriform
plate and
paranasal sinuses. Post-surgical changes including bifrontal
craniotomy and cranialization of the frontal sinuses, with
osseous metallic plates unchanged in configuration although and
mild increase of complex fluid is demonstrated within the
intracranial post-surgical bed. Degree of pneumocephalus has
decreased since prior study, yet right frontal subgaleal air has
increased in the interim. Linear region of calcified
hyperattenuation separating the cerebral hemispheres from the
post- craniotomy fluid collection remains stable; however, the
degree of mass effect upon the frontal horns of the lateral
ventricles has decreased, suggesting decreasing edema within the
cerebral hemispheres. No shift of normally-midline structures is
demonstrated. The major basal cisterns are preserved. A large
amount of hemorrhage and opacification is again demonstrated
within the right maxillary, ethmoid and sphenoid sinuses
extending into the posteriorly-deroofed frontal sinuses which is
contiguous with the intracranial postsurgical bed. An unusual
linear collection of air is demonstrated within the
post-surgical fluid collection, possibly collecting underneath a
faint septation or fibrous band (2:23). No intracranial drain is
identified to otherwise account for this finding (and none is
mentioned in the operative report). The mastoid air cells again
demonstrate patchy opacification, bilaterally.
IMPRESSION:
1. Mild increase in complex fluid within the post-surgical bed
with shift of pneumocephalus, extracranially, to the right
frontal subgaleal space.
2. Decreased effacement of bilateral frontal horns suggests
decreased edema within bilateral cerebral hemispheres, with
decreased mass effect. No new intracranial herniation or shift
of normally-midline structures demonstrated.
MRI Head [**2131-5-12**]:
FINDINGS: There is an enormous collection of gas, with a
2-tiered fluid
level, with T2 hyperintense components superiorly and T2
hypointense
components on the more dependent side of the fluid collection.
This
area/fluid mixture lies in the extradural compartment, and
presumably connects with the operative bed. There is a
considerable amount of fluid within the right maxillary sinus,
with loss of aeration of the sphenoid sinus, particularly on the
right side, as well as considerable high T2 signal, with some
fluid levels within the mastoid sinuses. Within the operative
bed is a mixture of T2 signal, some of which appears similar in
distribution to the preoperative images of the tumor seen near
the posterior aspect of the right cribriform plate. It is very
difficult, on the basis of this study, to be certain whether
there has been complete removal of the tumor. The large frontal
air-fluid collection causes marked compression of the brain,
with telescoped appearance of the corpus callosum. Marked
compression of the frontal horns is seen, but there is no
subfalcine or transtentorial herniation. There is considerable
pachymeningeal enhancement throughout the supratentorial region.
Enhancement along the clivus is seen extending into the right
internal auditory canal. However, review of the preoperative
study appears to show some clival enhancement extending towards
the right porus acusticus. While the present study's
pachymeningeal enhancement may be a reflection of the extensive
recent operation, the preoperative enhancement raises the
possibility of venous distention, versus pachymeningeal spread
of tumor. This latter diagnosis is of some concern, particularly
in light of the enhancement in the right internal auditory
canal. There is no area of pathological enhancement within the
brain parenchyma itself.
CONCLUSION: Large intracranial gas/fluid collection posteriorly
displacing
the frontal lobes. The fluid may have blood components
accounting for the
two-tiered appearance, noted above. Additional findings, as
noted above.
CT Head [**5-14**]:
IMPRESSION:
1. Mild increase in complex fluid within the post-surgical bed
with shift of pneumocephalus, extracranially, to the right
frontal subgaleal space.
2. Decreased effacement of bilateral frontal horns suggests
decreased edema within bilateral cerebral hemispheres, with
decreased mass effect. No new intracranial herniation or shift
of normally-midline structures demonstrated.
EKG [**5-16**]:
Sinus rhythm with ventricular premature complexes in bigeminy
pattern
Modest nonspecific ST-T wave changes,No previous tracing
available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 156 90 [**Telephone/Fax (2) 64685**]
Brief Hospital Course:
Patient was electively admitted on [**5-10**] for previously planned
bifrontal craniotomy with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 1837**](ENT).
Post operatively, he was transferred to the ICU where he
remained intubated until [**5-11**]. He still required nicardipine for
systolic pressure control, and lethargic, but following
commands. On [**5-12**] MRI was completed and revealed expected
post-surgical changes. The lumbar drain was clamped as well. On
[**5-13**], he continued to have persistent lethargy and a repeated
head CT was performed, revealing some sulcal effacement. A one
time dose of mannitol was given for this indication. Head CT was
repeated on [**5-14**]; and determined to be slightly improved from the
mannitol. He continued to not have any obvious leak of CSF, so
lumbar drain was removed on [**5-14**]. On [**5-15**], he was significantly
more lucid, with full strength throughout upper and lower
extremities, passed speach and swallow, and subsequently
transferred to the neurosurgical stepdown unit. On [**5-16**] he had a
short burst of bigeminy, remaining normotensive. The cardiology
service was curbsided, and they recommended the addition of a
beta blocker. This was done with appropriate effect. On [**5-17**] he
was seen and evaluated by PT and OT who recommended that he be
discharged to home with services. On the morning of [**5-18**], he was
discharged accordingly with instructions to follow up with his
home oncologist; and instructions for suture removal.
Medications on Admission:
ASA 81mg', Norvasc 5mg/hs, Prilosec 20mg', Altace 10mg"
Discharge Medications:
1. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Outpatient Occupational Therapy
10. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
County Public Health Department, [**Location (un) 64684**] NY
Discharge Diagnosis:
metastatic melanoma
bigeminy
Discharge Condition:
Neurologically Stable
Discharge Instructions:
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures have been removed.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**7-20**] days (from your date of
surgery- [**5-21**]) for removal of your staples & sutures and a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
**You should otherwise call to make an appointment to see Dr.
[**Last Name (STitle) **] in approximatley 4 weeks. You will require a non-contrast
Head CT prior to your appointment. This can also be scheduled
for you when you call. The office phone number is [**Telephone/Fax (1) 1669**].
**Also make sure to make a follow up appointment with your
oncologist at home, Dr. [**Last Name (STitle) 64686**].
Completed by:[**2131-5-19**]
|
[
"198.5",
"V10.82",
"E870.0",
"198.89",
"197.3",
"427.89",
"348.8",
"349.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.5",
"21.30",
"22.42",
"02.12",
"22.63"
] |
icd9pcs
|
[
[
[]
]
] |
9317, 9409
|
6843, 8360
|
319, 669
|
9482, 9506
|
2125, 6820
|
10933, 11748
|
1919, 1937
|
8466, 9294
|
9430, 9461
|
8386, 8443
|
9530, 10910
|
1952, 1952
|
1966, 2106
|
249, 281
|
697, 1475
|
1497, 1795
|
1811, 1903
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,257
| 198,125
|
40095
|
Discharge summary
|
report
|
Admission Date: [**2153-11-7**] Discharge Date: [**2153-11-19**]
Date of Birth: [**2077-4-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x3 with the left internal
mammary artery to the left anterior descending artery and
reverse saphenous vein graft to the right coronary artery and
the ramus intermedius artery.
History of Present Illness:
76 year old male who over past several months has been noticing
increasing dyspnea with exertion. Can climb 3 flights of stairs
but now gets shortness of breath in doing so. Had alteration 2
weeks ago, at that time was hit in neck and fell, no medical
care at that time. Subsequently saw PCP had MRI(neg) and EKG
that revealed ST changes, no chest pain at that time. Persantine
stress revealed fixed apical defect with septal ischemia.
Referred for cardiac catheterization [**11-7**] which showed
LAD-complex calcified lesion- subtotal occlusion Ramus
RCA-diffuse calcified mid lesion 50%
Cardiac Echocardiogram:[**2153-10-19**]
EF 55% mild concentric hypertrophy w/diastolic stiffness
AV-normal
MV-Mild MR, moderate annular calcification TV-mild TR PASP
37mmHg/RAP 14mmHg
PV-normal. Referred for cardiac surgery
Past Medical History:
Hypertension, hypercholesterolemia, Prostate CA(rad), Gout,
Depression, Gastric ulcer [**2151**]
Past Surgical History: Rt CEA [**2150**], Rt knee arthroscopy
Social History:
Race: Caucasian
Last Dental Exam: last year
Lives with: alone
Occupation: retired oil truck driver
Tobacco: quit 50 years ago
ETOH: quit 2 years ago-past heavy ETOH
Family History:
Family History: noncontributory-no early CAD
Physical Exam:
Temp98 Pulse: 43 SB Resp: 18 O2sat: 99%-2LNP
B/P Right: 150/82 Left:
Height: 70.5" Weight: 90kg
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] No M/R/G
Abdomen: Soft[x] non-distended [x] non-tender[x] +bowel
sounds[x]
Extremities: Warm [x], well-perfused [] Edema: none
Varicosities: None [x] PVD color changes below knees
Neuro: A&O x3, MAE follows commands. Nonfocal exam
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit no
Pertinent Results:
[**2153-11-15**] 02:26AM BLOOD WBC-9.9 RBC-3.45* Hgb-11.4* Hct-32.5*
MCV-94 MCH-33.2* MCHC-35.1* RDW-15.2 Plt Ct-143*
[**2153-11-15**] 02:26AM BLOOD Glucose-85 UreaN-21* Creat-1.1 Na-134
K-3.9 Cl-99 HCO3-26 AnGap-13
[**2063-11-8**]:
Echo:
Prebypass
No atrial septal defect is seen by 2D or color Doppler. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are complex (>4mm) atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was
notified in person of the results on [**2153-11-8**] at 1515
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Mild mitral
regurgitation present. Aorta is intact post decannulation.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2153-11-8**] where he underwent a coronary artery
bypass grafting x3 with the left
internal mammary artery to the left anterior descending artery
and reverse saphenous vein graft to the right coronary artery
and the ramus intermedius artery.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
He did become confused, aggitated, paranoid and aggresive on
post operative day 2 and was treated with Ativan and Haldol with
thoughts of alcohol withdraw. A head CT was done [**11-11**] and [**11-12**]
due to continued confusion which showed no acute intracranial
injury and mucosal thickening of the anterior ethmoid air cells.
He did have a brief episode of atrial fibrillation and was
treated with IV and oral Amiodarone with return to sinus rhythm.
Beta blocker was initiated and titrated up and the patient was
gently diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 11 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to [**Hospital3 15644**] Health Care Center in
[**Location (un) 47**] in good condition with appropriate follow up
instructions.
Medications on Admission:
Diltiazem 240 QD
Simvastatin 20 QD
Atenolol 12.5 QD
ECASA 81 QD
Paroxetine 10 QD
Probenecid 500 QD
B12 1000 QD
Vit D 1000 QD
Colchicine 0.6-prn
Added at [**Hospital3 1280**]-
Norvasc 5 QD
ASA ^325 QD
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 2 weeks, then 400mg daily x 1 week, then
200mg daily until further instructed.
4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. probenecid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush for 4 days.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
17. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: MD to dose daily for goal INR 2-2.5, dx: a-fib.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Care - [**Location (un) 47**]
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema- 1+ edema b/l LEs
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**2153-11-28**] @ 2pm
Cardiologist: Dr. [**Last Name (STitle) **] [**Name (STitle) 8051**] [**2153-12-4**] @ 10AM
Please call to schedule appointments with your
Primary Care Dr. [**Known firstname **] [**Last Name (NamePattern1) 11427**] in [**4-2**] weeks ([**Telephone/Fax (1) 8052**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2153-11-19**]
|
[
"458.29",
"287.5",
"401.9",
"274.9",
"427.31",
"511.9",
"427.32",
"V10.46",
"414.01",
"311",
"272.4",
"291.0",
"997.1",
"305.00",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
7307, 7395
|
3631, 5408
|
331, 541
|
7463, 7693
|
2522, 3608
|
8617, 9189
|
1784, 1815
|
5659, 7284
|
7416, 7442
|
5434, 5636
|
7717, 8594
|
1528, 1569
|
1830, 2503
|
272, 293
|
569, 1386
|
1408, 1505
|
1585, 1752
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,815
| 101,896
|
49345
|
Discharge summary
|
report
|
Admission Date: [**2196-5-4**] Discharge Date: [**2196-5-13**]
Date of Birth: [**2143-5-24**] Sex: M
Service: MEDICINE
Allergies:
Compazine / Methotrexate / Ceftazidime
Attending:[**First Name3 (LF) 21731**]
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Transesophageal [**First Name3 (LF) **]
History of Present Illness:
Mr. [**Known lastname **] is a 52yo M with Crohn's disease s/p multiple
surgeries with resultant short gut syndrome and TPN dependency
who was recently admitted to [**Hospital1 18**] for evaluation of low grade
fevers. The pt has a history of multiple line infections, MV
endocarditis and osteomyelitis for which the pt is on chronic
vancomycin. The pt initially presented to the ED on [**2196-4-21**] at
which time he was started empirically on levofloxacin and sent
home. Fevers continued at home and the pt was subsequently
admitted to [**Hospital1 18**] on [**2196-4-26**] with Tmax of 102 in the ED. Of
note, the pt also had elevated LFT but with normal US and normal
ERCP. The pt was placed on unasyn with gradual reduction in
fever curve. At the time, an extensive workup was performed,
however the pt was discharged with continuing low grade fevers.
The pt was discharged on [**2196-4-29**] with continuing low grade
temperatures.
Since his discharge from [**Hospital1 18**], the pt reports continual low
grade fevers. The pt has a 24hour RN service who had recorded a
Tmax of 102 this AM as well as sx of disorientation. The pt
admits to fevers as above but denies any chills, rigors, night
sweats, chest pain, palpitations, abd pain, n/v, head ache,
photophobia, neck stiffness. The pt admits to chronic diarrhea
secondary to his short gut syndrome but there has not been any
change in his stool frequency or characteristic. The pt does
report orthopnea and some LE edema which has been ongoing for
over one year. The pt does report some mild weight gain over
the course of the last couple of months but no change in his
appetite. The pt denies any heat or cold intolerance, or
flushing.
In the ED, the blood cultures were drawn, UA and urine
cultures were sent and a CXR was performed. LFT and ESR was
added on. A TTE and CT scan of the chest, abd and pelvis was
also performed.
Past Medical History:
1. Crohn's disease s/p multiple surgeries with resultant
ileostomy and shortgut syndrome dependent on TPN with chronic
hypocalcemia, vitamin D deficiency.
2. [**Hospital1 **]: Staph epidermidis C4-C5 Osteomyelitis (On
Chronic Vancomycin), Endocarditis with Mitral Valve [**Hospital1 **],
[**Hospital1 **] Polymicrobial Line Sepsis, Previous RLL PNA, LE
Cellulits
3. Respiratory - COPD (Baseline PaCO2 of 48), H/O ARDS with
Intubations/Tracheostomy ([**2192**] and [**2193**]).
4. Severe MR
5. CKD (Baseline Cr 1.3 to 1.4)
6. Anemia of Chronic Inflammation (on EPO)
7. Mild Dementia
8. Chronic Pain (Fentanyl 50 mcg Patch)
9. Restless Leg Syndrome
10. Steroid-Induced Osteoporosis
11. Multiple Spinal Compression Fx
12. Peripheral Neuropathy
13. UGIB/Duodenal Ulcer ([**2193**])
14. Depression
15. Bilateral SVC Thrombi.
Social History:
Lives alone; 24[**Hospital 8018**] nursing care with multiple nurses; fully
intact ADLs; ambulates without assistance; never married; has no
children; has worked many odd jobs; he has five brothers and one
sister that are very supportive. His three brothers, [**Name (NI) **],
[**Name (NI) **], and [**First Name8 (NamePattern2) **] [**Name (NI) **], are all his health care proxies. He
smokes one to one and a half packs per day; has a 60-pack-year
history of smoking. He reports minimal alcohol use and previous
use of marijuana but denies any IVDU. Pt does admit to previous
blood transfusions, he has never exchanged sex for money and he
does not remember if he has ever had an HIV test. Full code.
Family History:
F: Crohn's disease
M: TIA in her 70s
GF: DM
Physical Exam:
GEN: middle aged caucasian male wearing baseball cap and lying
on stretcher. Pt appears comfortable in NAD. Pt conversing
fluently in full sentences. No accessory muscle use.
Skin: warm to touch, slight jaundice, no obvious rashes or
lesions.
HEENT: EOMI, slightly icterics, mmm, op clear
Neck: full rom, difficult to assess suppleness due to some
guarding by pt.
CV: [**1-24**] holosystolic murmur heard best over the LLSB without
radiation.
Chest: clear to auscultation bilaterally, line site on left
chest appears to be clean and intact without signs of erythema,
induration, tenderness, or discharge.
Abd: soft, NT, ND, ostomy bag full of greenish-brown stool and
air in the bag. stoma is pink and moist. BS+
Ext: wwp, trace to +1 pitting edema bilaterally, PT +1
bilaterally
Brief Hospital Course:
A/P: 52yo M with Crohn's disease s'p multiple surgeries
complicated by shortgut syndrome and dependency on TPN with hx
of multiple line infections, endocarditis and osteomyelitis.
.
1. Fever: Initially felt to be septic with SBP in 90's.
Cultures were initially negative, clear CXR, fungal cx negative.
TEE was performed which showed reappearance of MV [**Month/Day (4) **] and
worsening MR. [**Name13 (STitle) **] was started on daptomycin, ambisome. Then found
to have fungal elements on blood smear, and then had a fungal
culture consistent with malassezia furfur. In addition gram +
cocci seen on the same blood smear and Staph epi grew out of 1
culture. Further identification is pending to determine if it is
a contaminant of the same organism that was present in his
osteomyelitis.Initially had wanted to have his Hickman pulled,
but per IR this would be a very difficult and involved procedure
and they prefer to treat through the line if possible. After ID
conference discussion plan is to treat with ambisome 3mg/kg IV
daily for 6 weeks, daptomycin 400 mg IV daily for 10 more days,
then transisiton to vancomycin 1g IV qod ongoing. He will need
to have f/u fungal cx with lipid supplemented media after 6
weeks to document clearance.
A). Cards: The pt has a history of endocarditis for which he
has previously undergone medical treatment. Given the
dependency on TPN, the pt is at significant risk for possible
endocarditis, especially with fungal organisms. TEE showed
slightly worsened MR [**First Name (Titles) **] [**Last Name (Titles) 16169**] MV [**Last Name (Titles) **]. Will plan 6
weeks ambisome with f/u cx. Daptomycin 400 mg IV daily for 10
more days, then vancomycin 1g IV qod. Had initially been
diuresed for CHF, now euvolemic.
.
B). Pulm: The fever is unlikely to be due to a pulmonary source
given his lack of focal signs or symptoms including lack of
cough, sputum. Initialy appeared in CHF after transfer out of
[**Hospital Unit Name 153**]. Diuresed well, now euvolemic.
.
C). GI/Liver: Patient's Crohn's disease appears to be stable,
without evidence of a hepatobiliary source by LFTs. No abdominal
pain, and able to take some pos.
.
D). Musculoskeletal: The pt has a known history of
osteomyelitis for which he is on chronic treatment with
vancomycin QOD (which is an unusual dose given his creatine
clearance would suggest a once daily to [**Hospital1 **] dosing). No neck or
back pain.
.
E). Lines: As stated above, the pt has an existing Hickman
catheter for his TPN and history of multiple line infections.
Will hold off on pulling Hickman at this time and will need to
be pulled if fungal BCx comes back positive after 6 weeks.
.
4. Renal: The pt has a history of CKD with creatinine baseline
in 1.2 range, now elevated at 1.8, looks dry on exam, giving IVF
now, will recheck chem 10 tomorrow, K elevated at 5.9 [**5-13**],
giving IVF and recheck today. Will need to have potassium free
TPN on discharge and repeat chem 10 [**5-14**].
.
5. FEN: low salt diet, replete electrolyts with cautions.
.
6. PPx: heparin sub Q TID for DVT prophylaxis, protonix for GI
ppx. Pt does not need bowel regimen given his chronic diarrhea.
.
7. Code status: full code
Medications on Admission:
MEDICATIONS:
1. Niferex 150mg [**Hospital1 **]
2. Protonix 40mg once daily
3. Imodium 4mg Q6hours
4. Vitamin C 500mg once daily
5. Tums 1250mg 5x/day
6. Rocaltrol 0.25mg once daily
7. Vitamin D 50,000u Qweek
8. Zestril 20mg once daily
9. Vancomycin 1gm IV Q48hours
10. Unasyn 3g IV Q8hours
11. Tylenol
12. Risperdal 0.25mg [**Hospital1 **]
13. Norvasc 2.5mg once daily
14. Zofran 4mg IV Q8hours PRN N/V
15. Erythropoietin 10,000SQ weekly
16. Glutamine 10 g powder 3x/day
17. Sandostain LAR depot30mg IM Qmonthly
18. Ativan 1mg QHS PRN
19. Ambien 5-10mg QHS PRN
.
ALLERGIES: NKDA
Discharge Medications:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO 5X/D
(5 times a day).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Glutamine 10 g Packet Sig: One (1) Packet PO TID (3 times a
day).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5,000
units Injection TID (3 times a day).
9. Opium 10 % Tincture Sig: 0.6 ML PO QID (4 times a day).
10. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
11. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed for insomnia.
12. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
13. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale sliding scale Injection ASDIR (AS DIRECTED).
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
15. Daptomycin 500 mg Recon Soln Sig: Four Hundred (400) mg
Intravenous Q24H (every 24 hours) for 10 days.
Disp:*qs 10 days* Refills:*0*
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed.
17. Amphotericin B Liposome 50 mg Suspension for Reconstitution
Sig: Two Hundred (200) mg Intravenous Q24H (every 24 hours) for
6 weeks: Will need mycolytic blood cultures with oil
supplemented media after completion.
Disp:*qs 6 weeks* Refills:*0*
18. Vancomycin 1,000 mg Recon Soln Sig: 1,000 mg Intravenous
every other day: Please start on [**2196-5-23**] (day after finishes
daptomycin course).
Disp:*qs 1 month* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Fungemia with Malassezia furfur
Bacterial/fungal endocarditis
Mitral valve regurgitation
Crohn's disease
Short gut syndrome
osteoporosis
Dependence on TPN
Discharge Condition:
stable
Discharge Instructions:
Please continue your regular medications. In addition please
continue ambisome 200 mg IV daily for next 6 weeks. Please
continue taking daptomycin for next 10 days then will change to
vancomycin 1g IV every other day ongoing. You will need to have
your creatinine checked every week and faxed to Dr. [**Last Name (STitle) 22874**] at
[**Telephone/Fax (1) 1419**]. After 6 weeks of therapy with ambisome you will
need mycolytic blood cultures with oil supplemented media to
make sure you have cleared your fungal infection. Please
continue to perform an amphotericin lock of your Hickman
catheter daily when not recieving medications or TPN (3cc of
1mg/ml amphotericin B to lock your Hickman catheter).
Followup Instructions:
1. Please have your Chem 7 checked [**2196-5-14**], as your K had been
elevated [**5-13**]. Please also have weekly Chem 10 drawn and faxed
to Dr. [**Last Name (STitle) 22874**].
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2196-6-2**] 11:00
2. Please follow up with Dr. [**Last Name (STitle) 5717**] in [**11-22**] weeks.
3. Please also follow up with Dr. [**Last Name (STitle) 79**] in [**12-25**] weeks.
|
[
"996.62",
"333.99",
"268.9",
"584.9",
"995.92",
"428.0",
"421.0",
"730.18",
"V58.62",
"E879.8",
"285.9",
"579.3",
"555.9",
"V44.2",
"E849.0",
"294.8",
"496",
"112.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"99.04",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10545, 10551
|
4743, 7949
|
306, 348
|
10750, 10758
|
11508, 12054
|
3873, 3918
|
8597, 10522
|
10572, 10729
|
7975, 8574
|
10782, 11485
|
3933, 4720
|
260, 268
|
379, 2288
|
2310, 3132
|
3148, 3857
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,447
| 156,943
|
6625
|
Discharge summary
|
report
|
Admission Date: [**2168-9-20**] Discharge Date: [**2168-10-19**]
Date of Birth: [**2095-7-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfasalazine
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
S/p fall, UTI, cellulitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 yo female with history of macular degeneration, HTN,
hypothyroidism, CBD obstruction with multiple stents/dilations,
PUD, recently treated UTI 2 weeks ago, and subacute 30 lb weight
loss who presents from [**Location (un) 620**] s/p fall. Pt states that she fell
at home this morning when she bent down over her radiator and
fell "on her butt". She states that the fall was purely
mechanical as she felt her knees give out. She denies any LOC or
dizziness, palpitations, chest pain or shortness of breath prior
to her fall. At [**Location (un) 620**], she was found to have a UTI, multiple
rib fxs (T9,10,11) and cellulitis of her right LE across the
anterior aspect of her tibia. She was given a dose of cefipime
and vancomycin and transferred to [**Hospital1 18**]. At [**Location (un) 620**], the pt was
hypotensive with SBP dropping to 90's. After her transfer she
was resuscitated with 2 L NS in the ED but remains tachycardic
with HR in 110's. Additionally, pt's lactate is 2.9. ROS + for
fever and chills x 3 days.
Past Medical History:
Peptic ulcer disease
Pernicious anemia, peripheral neuropathy
Hypertension
Hyperlipidemia
Macular degeneration
Hyperthyroidism
Migraines
Anxiety
Heart murmur
Infrarenal AAA
S/p Partial gastrectomy with Bilroth 1 for PUD in [**2146**]
S/p "Gastric aneurysm" repair in [**2157**]
S/p appendectomy
S/p total hysterectomy
S/p cesarean section x2
S/p ventral hernia repair with mesh in [**2158**].
S/p C5-C6 fusion
Social History:
Divorced, Retired psychologist. Lives by herself. No tobacco.
4-5 drinks/week.
Family History:
Father with lung ca at 79. Mother with leukemia at 84.
Physical Exam:
ON ADMISSION:
Vitals: BP: 114/76, P: 114, R: 12, O2: 96% RA
General: Alert, oriented, no acute distress
Neck: supple, JVP not elevated, no LAD
Lungs: Dificult to auscultated, faint breath sounds, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: distended, tense, diffusely mildy tender to palpation,
bowel sounds present, no rebound tenderness or guarding,
organomegaly difficult to assess given distention. well healed
scars from previous surgeries noted.
GU: foley
Ext: warm to touch, + pulses, edematous in upper and lower
extremities.
Skin: Bilateral shins are warm to touch with 2+ pitting edema to
above the knee caps, tender to palpation in all regions below
the knee. Left leg only examined beneath dressing, revealing
patchy erythema without clear demarcations throughout the lower
extremity. 2 ulcers present, oozing clear fluids, stage I
appearing.
.
ON DISCHARGE:
VS: Afebrile, VSS
General: Comfortable, no acute distress
HEENT: PEERL, EOMI, no icterus, oropharynx clear, MMM
Neck: Supple, no LAD, no thyromegaly, no JVD
Lungs: CTAB, no wheezes or crackles
CV: RRR, normal S1 + S2, no M/R/G
Abdomen: Soft, NT, ND, NABS
Ext: 2+ pulses, trace edema in b/l lower extremities.
Skin: RLE and LLE ulcers healing well with scabs, minimal
erythema, covered with sterile dressing and wrapping clean and
dry
Neuro: A&Ox3, no memory deficits, CN II-XII intact, motor and
sensory function grossly intact, gait steady without assistance
Pertinent Results:
[**Hospital1 **] [**Location (un) **] UA (no Ucx sent):
[**2168-9-6**] 0-2 RBC, [**5-16**] WBC, few UES, loaded bact, no casts or
crystals seen
.
ADMISSION LABS:
[**2168-9-20**] 06:30PM BLOOD WBC-20.7*# RBC-3.46* Hgb-10.6* Hct-32.8*
MCV-95# MCH-30.7 MCHC-32.3 RDW-16.9* Plt Ct-336
[**2168-9-20**] 06:30PM BLOOD Neuts-87* Bands-0 Lymphs-7* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2168-9-20**] 06:30PM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-133
K-3.5 Cl-98 HCO3-25 AnGap-14
[**2168-9-20**] 06:30PM BLOOD ALT-28 AST-31 AlkPhos-175* Amylase-19
TotBili-0.3
.
URINALYSIS:
[**2168-9-20**] 04:18PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2168-9-20**] 04:18PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2168-9-20**] 04:18PM URINE RBC-0-2 WBC-21-50* Bacteri-MOD Yeast-NONE
Epi-0-2
.
OTHER LABS:
[**2168-9-22**] 12:53AM BLOOD calTIBC-92* VitB12-1178* Folate-5.5
Ferritn-129 TRF-71*
[**2168-9-22**] 12:53AM BLOOD TSH-6.1*
[**2168-9-23**] 07:25AM BLOOD Free T4-0.69*
[**2168-9-21**] 12:10AM BLOOD CEA-8.7* CA125-51*
.
DISCHARGE LABS:
[**2168-10-18**] 05:35AM BLOOD WBC-6.9 RBC-2.97* Hgb-8.9* Hct-27.8*
MCV-94 MCH-30.1 MCHC-32.2 RDW-15.6* Plt Ct-301
[**2168-10-18**] 05:35AM BLOOD PT-11.8 PTT-30.1 INR(PT)-1.0
[**2168-10-18**] 05:35AM BLOOD Glucose-68* UreaN-22* Creat-0.9 Na-137
K-4.2 Cl-102 HCO3-29 AnGap-10
.
MICRO:
[**9-20**] Urine Cx: mixed flora c/w contamination
[**9-20**] Blood Cx: no growth
[**9-21**] Blood Cx: no growth
[**9-22**] Urine Cx: no growth
[**10-3**] RLE ulcer swab Cx: no growth
.
IMAGING:
[**9-20**] CT head: Right frontal extra-axial hypodense fluid
collection with
remodeling of bone likely represents a right frontal arachnoid
cyst. No acute intracranial hemorrhage.
.
[**9-20**] CT c-spine:
1. No acute fracture.
2. Multilevel degenerative changes including grade 1
anterolisthesis of C3 on C4 and retrolisthesis of C4 on C5 and
C5 on C6 with mild spinal canal narrowing. Minimal bilateral
neural foraminal narrowing at C5-C6 is noted.
3. Punctate calcification in the right thyroid lobe.
4. Mild emphysematous changes of the lung apices.
.
[**9-20**] CT torso:
1. Minimally displaced acute right-sided rib fractures involving
ninth, tenth and eleventh ribs.
2. Infrarenal abdominal aortic aneurysm is larger compared to
[**2165-8-22**] now measuring 36 x 31 mm.
3. Hypodensities within bilateral kidneys are too small to
characterize, but likely represent renal cysts.
4. Stable pneumobilia.
5. Bilateral emphysematous changes of lungs.
6. Mild dilatation of the left subclavian artery at its origins.
7. Massive dilatation of the bladder with anterior diverticulum.
Foley catheterization is recommended.
Imaging Study: CT reread for colon, adnexa, pancreas: No
abnormalities in colon although no contrast so not optimal
study, hypotrophic uterus, no abdnormalities in adnexa or
pancreas. Mild non pathologic abdominal adenopathy.
.
[**9-20**] B/L knee/tib-fib x-rays: No fracture or dislocation in
either knee, tibia, or fibula. If there is continued clinical
concern for an ankle injury, consider dedicated views of these
regions.
.
[**9-21**] LE arterial dopplers: Difficult to interpret study due to
significant patient movement with artifact, but appears to be
aortobiiliac occlusive disease and likely multisegmental
component.
.
[**9-23**] UE venous dopplers: No evidence of deep vein thrombosis in
either arm
.
[**9-29**] B/L LE veins: No evidence of deep vein thrombosis in either
leg.
.
[**10-4**] U/S right leg: Subcutaneous edema corresponding with site
of known right leg ulcer. No evidence of drainable abscess.
Brief Hospital Course:
73 yo woman with macular degeneration, HTN, hypothyroidism,
pernicious anemia, and subacute 30 lb weight loss who presents
from [**Location (un) 620**] s/p fall. At [**Location (un) 620**] she was found to have a UTI,
multiple right-sided rib fractures (9,10,11) and cellulitis of
her right LE. She was given a dose of cefepime and vancomycin.
She was hypotensive with SBP dropping to 90's and was
transferred to [**Hospital1 18**] for treatment of suspected urosepsis. Brief
hospital course by problem:
.
# Suspected sepsis: Pt was continued on ciprofloxacin for the
UTI and vancomycin for the cellulitis. She remained afebrile and
hemodynamically stable, and WBC improved. Blood cultures were
negative.
.
# Urinary tract infection: Urinalysis at [**Hospital1 **] [**Location (un) 620**] suggestive
of UTI. She was started on cefepime however no urine culture was
sent. Initial concern for urosepsis given SBP 90s which was
fluid responsive. Antibiotics changed to ciprofloxacin here. No
organism was isolated on urine or blood cultures here. Pt
completed a 10-day course of ciprofloxacin and is currently
asymptomatic.
.
# Cellulitis: Completed 14-day course of IV vancomycin with
improvement in symptoms.
.
# LE ulcers: Patient has several chronic lower extremity ulcers
which have clean borders, no drainage, and no evidence of
infection. An ultrasound of the RLE ulcer on the anterior leg
showed no evidence of fluid collection or abscess. A wound
culture was negative for growth. The wound care team was
consulted and recommend cleaning the ulcers with commercial
wound cleanser daily, covering with a dry sterile dressing, and
keeping the legs elevated.
.
# LE pain: Despite treating the cellulitis and well-healing LE
ulcers, the pt continues to report pain in her lower
extremities. It is unclear what the cause of her pain is. She is
currently written for percocet 1-2 tabs Q6h PRN and has been
taking the full 2 tabs Q6h + 1 or 2 extra tabs overnight upon
request. She has been reisistant to tapering this dosing. We are
discharging her with a prescription for a 4-day supply of
percocet, and recommend that her PCP readdress whether this is
the optimal medication for pain control.
.
# Rib fractures: Fractures are located on right 9th, 10th, and
11th ribs. Surgical management not indicated. Recommend tylenol
PRN pain control.
.
# Weight loss: Pt endorses recent 30-lb weight loss. She reports
decreased appetite and PO intake in the setting of social
stressors. TSH was slightly elevated and free T4 was slightly
low. However, these are difficult to interpret in the setting of
illness in the hospital. No changes were made to her
levothyroxine dosing and repeat outpatient thyroid studies are
recommended. Pt reports occasional decreased mood, but no
clinical evidence of major depression. CT torso unremarkable.
CEA and CA-125 were mildly elevated so the CT was re-read with
more careful attention to the GI/GU tract, however no pathologic
findings were seen. Clinical breast exam did not reveal masses,
however outpatient mammogram is recommended. [**Month (only) 116**] also consider
outpatient colonoscopy. Recommend repeat CA-125.
.
# Hypothyroidism: TSH elevated, free T4 was low. Difficult to
assess significance of thyroid function tests as an inpatient.
Continued on levothyroxine per home regimen. Recommend repeat
thyroid function tests followed up as an outpatient.
.
# Anemia: Normocytic. No evidence of active blood loss and
ferritin of 129 is less suggestive of iron deficiency anemia
although RDW is elevated which may point to anemia chronic
illness. Outpatient colonoscopy is recommended to rule out
malignancy.
.
# Infrarenal abdominal aortic aneurysm: Larger compared to study
in [**8-/2165**], now measuring 36 x 31 mm. Evaluated by the vascular
surgery service who felt that there is no need to intervene at
this time. Arterial dopplers showed no insufficiency. Recommend
repeat CT in 1 year.
.
# Hypertension: Patient's triamterene-HCTZ and furosemide were
initally held in the setting of hypotension and suspected
sepsis. The furosemide was eventually restarted, however the
triamterene-HCTZ was not restarted since the patient has [**Doctor First Name **]
normotensive.
.
# Hyperlipidemia: The patient's PMH included hyperlipidemia
although she is not currently on any cholesterol medications.
Would recommend outpatient fasting cholesterol panel.
.
# Gout: Stable, asymptomatic. Patient's outpatient medication
list does not include any medications for this and pt states
that she is not taking allopurinol or colchicine.
.
# Anxiety/Depression: Patient is occasionally tearful and
anxious but mood is good. Continued home doses of valproic acid
and wellbutrin.
.
# Deconditioning: Pt was initially unsteady on her feet and had
had several falls prior to being admitted to [**Hospital1 18**]. She was
screened for rehab, however did not qualify for this due to
problems with her insurance. She has been eating more and
working with PT and was found to be safe for discharge home.
There is a question of the patient's daughter stealing money
from her, so we have arranged for elder services to follow up
with the patient upon discharge.
.
# Code status: DNR/DNI
.
**A copy of the discharge summary was faxed to the pt's PCP [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22882**].**
Medications on Admission:
*Medication list was obtained from records and confirmed with
the patient.
1. Levothyroxine 25 mcg daily
2. Allopurinol (not taking)
3. Colchicine (not taking)
4. Triamterene-HCTZ 37.5-25mg daily
5. Flexeril (not taking)
6. Lorazepam 0.25 mg Q4h PRN
7. Valproic acid 500 mg QHS
8. Bupropion SR 150 mg [**Hospital1 **]
9. Furosemide 20 mg daily
10. Docusate 100 mg [**Hospital1 **]
11. Bisacodyl 10 mg PRN
12. Oxycodone 5 mg daily PRN
13. Tylenol 325 mg 1-2 tabs Q6h PRN
14. Pantoprazole 40 mg daily
15. Naproxen 750 mg Q12 PRN
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
2. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as
needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
3. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO QHS (once a day (at bedtime)).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Lorazepam 0.5 mg Tablet Sig: 0.5 to 1 Tablet PO three times a
day as needed for anxiety: Take no more than 4 tablets per day.
Disp:*20 Tablet(s)* Refills:*0*
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for fever or pain.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Naproxen 250 mg Tablet Sig: Three (3) Tablet PO twice a day
as needed for pain.
10. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours).
Disp:*24 Tablet(s)* Refills:*0*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Outpatient Physical Therapy
Patient requires outpatient physical therapy evaluation.
Discharge Disposition:
Home
Discharge Diagnosis:
Rib fractures
Urinary tract infection
Cellulitis
Lower extremity stage I ulcers
Abdominal aortic aneurysm
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname **],
You were transferred from [**Hospital1 **] [**Location (un) 620**] for management of rib
fractures, a urinary tract infection, and cellulitis (a skin
infection). Surgery was not indicated for your fractures. Your
urinary tract infection and cellulitis were treated with
antibiotics. Vascular surgery evaluated you for an enlarging
abdominal aortic aneurysm which was found on an ultrasound, but
felt that this could be watched for now. You will need a
follow-up CT scan to reevaluate the abdominal aortic aneurysm in
1 year. Lastly, you described significant weight loss in the
past several weeks. The imaging studies that we did didn't show
any concerning findings but you will need to undergo routine
cancer screening by your primary care doctor. [**First Name (Titles) **] [**Last Name (Titles) 3690**]
recommended that you eat a high-protein diet with mealtime
supplements. Our physical therapists have been working with you
and feel that you are steady on your feet and do not need
further physical therapy or a walker.
.
Please continue to take your home medications. We have made the
following changes:
- STOPPED triamterene-HCTZ because your blood pressure has been
normal
- STARTED percocet 1-2 tablets every 6 hours as needed for pain.
We are giving you enough pills to last for 4 days. You should
speak to your PCP about continuing this. Do not drive while
taking this medication.
.
You need to continue having the dressings on your right shin
changed two or three times a week. You can have that done at Dr. [**Name (NI) 25331**] office. Arrange those appointments when you see him in
clinic on Thursday. They will use a non-adherent dressing,
wrapped with gauze. Please keep your legs elevated as much as
possible.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22882**] (primary care doctor)
Friday, [**10-21**] at 10:00AM
[**Street Address(2) 25332**], [**Location (un) 620**], [**Numeric Identifier 3002**]
([**Telephone/Fax (1) 25333**]
.
Please contact the RIDE to arrange transportation to your
appointments with him.
.
Department: VASCULAR SURGERY
When: THURSDAY [**2169-9-21**] at 10:30 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
.
Department: VASCULAR SURGERY
When: THURSDAY [**2169-9-21**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2168-10-19**]
|
[
"346.90",
"261",
"V12.04",
"707.21",
"401.9",
"441.4",
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"300.4",
"995.91",
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"807.03",
"272.4",
"599.0",
"682.6",
"707.19",
"V45.79",
"369.4",
"V12.71",
"459.81",
"276.51",
"V49.86",
"038.9",
"V45.4",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14618, 14624
|
7156, 7632
|
300, 307
|
14787, 14787
|
3492, 3638
|
16749, 17656
|
1906, 1963
|
13107, 14595
|
14645, 14766
|
12556, 13084
|
14970, 16726
|
4610, 5100
|
1978, 1978
|
2911, 3473
|
235, 262
|
7660, 12530
|
335, 1361
|
5109, 7133
|
3654, 4362
|
1992, 2897
|
14802, 14946
|
1383, 1794
|
1810, 1890
|
4374, 4594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,751
| 166,917
|
5241
|
Discharge summary
|
report
|
Admission Date: [**2129-5-10**] Discharge Date: [**2129-5-13**]
Date of Birth: [**2058-7-30**] Sex: F
Service: ACOVE-IM
HISTORY OF PRESENT ILLNESS: This is a 70 year old woman
with a history as outlined below who was recently admitted
[**4-29**] until [**2129-5-6**], for bilateral lower extremity
cellulitis and congestive heart failure, who now presents
with respiratory distress, fever and change in mental status.
She had been discharged on Augmentin for cellulitis on [**5-6**]. She was doing well until [**5-9**], when she was found to
have an increased respiratory rate, fever to 102.0 F., and
decline in mental status. She was given 80 mg of intravenous
Lasix with 600 cc. of urine output. She was also given one
gram of Ceftriaxone intravenously at her Nursing Home but
because of continued respiratory distress was sent to the
[**Hospital1 69**] Emergency Room and then
admitted to the Medical Intensive Care Unit for observation
for two nights.
In the Emergency Room, she was given Flagyl and intravenous
fluids. Her arterial blood gases on admission were
7.4/45/78. White blood cell count was 10.3, 3.6 previously,
and chest x-ray showed new left lower lobe pneumonia.
PAST MEDICAL HISTORY:
1. Mild mental retardation.
2. Coronary artery disease.
3. Congestive heart failure.
4. Ejection fraction of 25 to 30%.
5. Type 2 diabetes mellitus with neuropathy.
6. Hypertension.
7. Cerebrovascular accident in [**2126**].
8. Chronic obstructive pulmonary disease.
9. Peripheral vascular disease.
10. Gastroesophageal reflux disease.
11. Tremor.
12. Hypothyroidism.
MEDICATIONS ON ADMISSION:
1. Synthroid 50 mcg q. day.
2. Heparin 5000 units subcutaneously twice a day.
3. Captopril 50 mg p.o. three times a day.
4. Enteric-coated aspirin 325 mg p.o. q. day.
5. Augmentin, day number seven.
6. Lopressor 75 mg p.o. twice a day.
7. Lasix 80 mg p.o. twice a day.
8. Coumadin 5 mg p.o. q. h.s.
9. Flovent MDI.
10. Atrovent MDI.
11. Effexor 37.5 mg p.o. q. day.
12. Neurontin 300 mg p.o. q. h.s.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives at [**Hospital 19497**]. She
is widow for approximately one year. Has a daughter who
lives in [**Name (NI) 8449**] and two grandsons who live in the [**Name (NI) 86**]
area.
PHYSICAL EXAMINATION: On admission, vital signs with
temperature of 38.9 C.; heart rate 110 to 120; blood pressure
145/75; O2 saturation 95% on four liters nasal cannula.
Respiratory rate 20 to 25. In general, the patient was
tachypneic, sleepy but arousable, following commands. HEENT
examination: Pupils are equal, round and reactive to light.
Extraocular muscles are intact. Dry mucous membranes.
Cranial nerves II through XII intact. Neck supple. Lungs
with crackles at the left base, good air movement, no
wheezes. Cardiovascular: Tachycardic. No murmurs.
Question of S3 gallop which is intermittent. Abdomen obese,
nondistended, nontender. Normoactive bowel sounds.
Extremities with two to three plus edema bilaterally. Areas
of erythema on legs bilaterally. Decreased in size from
previous line. No rash. Warm extremities. Neurological:
Moving all four extremities. Reflexes two plus bilaterally,
biceps/knee.
LABORATORY DATA: White blood cell count 10.7, 88%
neutrophils, hematocrit 36, platelets 437.
Sodium 145, chloride 108, bicarbonate 27, BUN 36, creatinine
1.2. Glucose 209, lactate 1.9, calcium 8.2, phosphorus 3,
magnesium 2. PT 18.9, PTT 30.7, INR 2.5.
Urinalysis with zero to two white blood cells, rare bacteria.
Blood cultures no growth to date. Urine culture [**5-10**],
negative urine culture, [**5-11**] pending.
Sputum Gram stain greater than 10 epithelial cells, four plus
budding yeast, three plus Gram positive cocci in clusters.
Culture pending.
Admission EKG with sinus tachycardia at 112, IVCD T wave
inversion in I and AVL. Nonspecific ST-T wave changes. No
change from EKG on [**2129-5-3**].
Chest x-ray with left lower lobe infiltrate versus
atelectasis, cardiomegaly, no clear congestive heart failure.
IMPRESSION: This is a 70 year old woman with congestive
heart failure, diabetes mellitus, and bilateral lower
extremity cellulitis admitted with respiratory distress,
fever and mental status changes, found to have new left lower
lobe pneumonia.
HOSPITAL COURSE:
1. Respiratory: Her pneumonia was treated with Levofloxacin
and Vancomycin intravenously. Flagyl was added for one day
on [**5-11**], but then discontinued after one dose, given
the low likelihood for aspiration pneumonia in her. She was
continued on MDIs and nebulizers and became clinically more
stable with resolving fever and O2 saturation by hospital day
number three.
2. Infectious Disease: As above, Levofloxacin and
Vancomycin for both pneumonia and to cover her cellulitis.
She was found to have a new Stage II sacral decubitus ulcer.
Blood cultures with no growth to date. It was decided not to
ask Plastics to come look at her sacral decubitus ulcer as it
appeared to be superficial and as there is good skin care
nurses at her Nursing Home.
3. Cardiac: History of congestive heart failure with low
ejection fraction. She was on Coumadin for low ejection
fraction. For some reason this was held at the Nursing Home
perhaps secondary to a super-therapeutic INR. It was
continued to be held in-house, however, she should restart it
once she is back at Star of [**Doctor Last Name **] with close following of her
INR with goal INR of 2.0 to 3.0. She was continued on her
beta blocker, aspirin, ACE inhibitor and Lasix during her
admission. She had one episode of transient supraventricular
tachycardia on Telemetry.
4. Renal / Fluids, Electrolytes and Nutrition: Renal
function was stable on admission. Creatinine bumped up to
1.3 on [**5-12**], but on [**5-13**], it was 1.0 again. She was
likely dehydrated, also because her sodium had risen, and was
given free water boluses gently via her nasogastric tube.
Despite the she continued with peripheral edema, any
hydration was done gently.
Once the patient was taking good p.o. on hospital day number
three, her nasogastric tube was discontinued and free water
was discontinued and she was encouraged to take good p.o.
5. Endocrine: Diabetes mellitus and hypothyroidism. She
continued on Regular insulin sliding scale and started on NPH
10 units twice a day and continued on Synthroid.
6. Mental status: This improved to her baseline with
resolution of her fever and respiratory distress.
7. Prophylaxis: On subcutaneous heparin and proton pump
inhibitor.
8. Code Status: FULL. Her sister is her health care proxy.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: [**Hospital 19497**].
DISCHARGE INSTRUCTIONS:
1. Fingerstick blood glucose four times a day before meals.
2. Wound care to bilateral legs and feet and to sacral
decubitus ulcer.
3. Cushioned boots to bilateral feet.
4. Please check PT, INR and electrolytes every three days;
goal INR of 2.0 to 3.0. Report results to M.D.
DISCHARGE MEDICATIONS:
1. Regular insulin sliding scale, zero to 150, no units; 151
to 200, 2 units; 201 to 250, 4 units; 251 to 300 units, 6
units; 301 to 350, 8 units; 351 to 400, 10 units; greater
than 400, 12 units and [**Name8 (MD) 138**] M.D.
2. NPH 10 units subcutaneously twice a day.
3. Flovent 110 mcg, four puffs p.o. twice a day.
4. Atrovent two puffs p.o. four times a day.
5. Lasix 80 mg p.o. twice a day.
6. Captopril 50 mg p.o. three times a day.
7. Dicloxacillin 500 mg p.o. four times a day times two
weeks.
8. Levofloxacin 500 mg p.o. q. day times two weeks.
9. Primidone 200 mg p.o. twice a day.
10. Neurontin 200 mg p.o. three times a day.
11. Synthroid 50 mcg p.o. q. day.
12. Effexor 37.5 mg p.o. q. day.
13. Ferrous sulfate 325 mg p.o. q. day.
14. Nystatin powder topically p.r.n.
15. Nystatin swish and swallow, 5 cc., p.o. q. six.
16. Heparin 5000 units subcutaneously twice a day.
17. Lopressor 75 mg p.o. twice a day.
18. Protonix 40 mg p.o. q. day.
19. Enteric-coated aspirin 325 mg p.o. q. day.
20. Tylenol 650 mg p.o. q. four hours p.r.n.
DISCHARGE DIAGNOSES:
1. Pneumonia.
2. Bilateral lower extremity cellulitis.
3. Congestive heart failure.
4. Diabetes mellitus.
5. Tremor.
6. Hypothyroidism.
7. Mental retardation.
8. Coronary artery disease.
9. Hypertension.
10. Cerebrovascular accident.
11. Chronic obstructive pulmonary disease.
12. Peripheral vascular disease.
13. Gastroesophageal reflux disease.
Please provide a copy of this discharge summary to [**Hospital **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 9755**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2129-5-13**] 18:23
T: [**2129-5-13**] 19:53
JOB#: [**Job Number 21431**]
cc:[**Hospital **]
|
[
"682.6",
"357.2",
"428.0",
"707.0",
"250.60",
"530.81",
"276.5",
"486",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8116, 8832
|
7038, 8095
|
1638, 2087
|
4321, 6398
|
6733, 7015
|
2312, 4304
|
171, 1212
|
6414, 6633
|
1234, 1612
|
2105, 2288
|
6658, 6709
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,673
| 114,326
|
7874
|
Discharge summary
|
report
|
Admission Date: [**2178-6-16**] Discharge Date: [**2178-6-29**]
Date of Birth: [**2149-2-26**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Ibuprofen / Codeine
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Exploratory Laparotomy with reivision of Jejunojejunostomy
History of Present Illness:
This is a 29 year old female who presents 1 week status-post a
laparoscopic roux-en-y gastric bypass with severe abdominal pain
after her cat jumped on her abdomen. The pain started acutely
and is [**8-24**], mostly in the left upper quadrant. She has had
some nausea with no emesis. Her last bowel movement was
yesterday. She has felt febrile. Prior to today she has
tolerated her stage 3 gastric bypass diet and had good pain
control
Past Medical History:
Morbid Obesity
Laparoscopic roux-en-y gastric bypass [**2178-6-8**]
hyperlipidemia
GERD
Colonic POlyps
B12 deficiency
[**Doctor Last Name **] Mal Seizures in childhood
Social History:
THe patient smokes half a pack per day and denies alcohol or
recreational
drugs. She lives with her fiance and 2 daughters.
Physical Exam:
ON admission:
101.7, 130, 148/82, 16, 96% room air
Gen: uncomfortable, distressed, alert/awake
CV: sinus tachycardia
Pulm: CTAB
GI: abdomen firm, tenderness to palpation in the left upper
quadrant, incisions c/d/i, no erythema, normoactive bowel sounds
Extr: no edema
Pertinent Results:
[**2178-6-15**] 06:40PM BLOOD WBC-13.9* RBC-4.72# Hgb-13.6# Hct-38.9#
MCV-83 MCH-28.7 MCHC-34.8 RDW-13.3 Plt Ct-416#
[**2178-6-16**] 02:38AM BLOOD WBC-17.5* RBC-4.47 Hgb-12.9 Hct-37.7
MCV-84 MCH-28.9 MCHC-34.2 RDW-13.3 Plt Ct-380
[**2178-6-17**] 03:02AM BLOOD WBC-15.6* RBC-3.37* Hgb-9.6*# Hct-27.8*
MCV-82 MCH-28.5 MCHC-34.6 RDW-13.7 Plt Ct-306
[**2178-6-18**] 03:00AM BLOOD WBC-15.7* RBC-3.38* Hgb-9.7* Hct-28.0*
MCV-83 MCH-28.6 MCHC-34.5 RDW-13.5 Plt Ct-320
[**2178-6-19**] 02:25AM BLOOD WBC-12.2* RBC-3.38* Hgb-9.9* Hct-28.2*
MCV-83 MCH-29.1 MCHC-35.0 RDW-13.4 Plt Ct-368
[**2178-6-20**] 05:08AM BLOOD WBC-14.9* RBC-3.73* Hgb-10.6* Hct-32.7*
MCV-88 MCH-28.5 MCHC-32.5 RDW-13.4 Plt Ct-370
[**2178-6-26**] 04:17AM BLOOD WBC-15.8* RBC-4.07* Hgb-11.6* Hct-33.5*
MCV-82 MCH-28.5 MCHC-34.6 RDW-13.2 Plt Ct-543*
[**2178-6-27**] 03:05PM BLOOD WBC-10.8 RBC-3.72* Hgb-10.3* Hct-30.7*
MCV-83 MCH-27.7 MCHC-33.6 RDW-13.1 Plt Ct-366
[**2178-6-15**] 06:40PM BLOOD Neuts-80* Bands-14* Lymphs-0 Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2178-6-16**] 03:15PM BLOOD Neuts-85.6* Bands-0 Lymphs-10.6*
Monos-3.4 Eos-0.2 Baso-0.3
[**2178-6-15**] 06:40PM BLOOD PT-14.3* PTT-34.7 INR(PT)-1.4
[**2178-6-19**] 02:25AM BLOOD PT-14.1* PTT-29.7 INR(PT)-1.3
[**2178-6-15**] 06:40PM BLOOD Glucose-98 UreaN-10 Creat-0.7 Na-135
K-3.5 Cl-99 HCO3-18* AnGap-22*
[**2178-6-16**] 03:15PM BLOOD Glucose-127* UreaN-7 Creat-0.6 Na-136
K-4.3 Cl-105 HCO3-23 AnGap-12
[**2178-6-18**] 03:00AM BLOOD Glucose-120* UreaN-5* Creat-0.4 Na-136
K-3.5 Cl-101 HCO3-28 AnGap-11
[**2178-6-20**] 05:08AM BLOOD Glucose-94 UreaN-8 Creat-0.4 Na-140 K-4.2
Cl-105 HCO3-25 AnGap-14
[**2178-6-26**] 04:17AM BLOOD Glucose-101 UreaN-13 Creat-0.7 Na-135
K-4.1 Cl-101 HCO3-24 AnGap-14
[**2178-6-27**] 03:05PM BLOOD Glucose-91 UreaN-7 Creat-0.4 Na-137 K-4.1
Cl-103 HCO3-23 AnGap-15
[**2178-6-15**] 06:40PM BLOOD ALT-43* AST-30 AlkPhos-97 Amylase-43
TotBili-4.8*
[**2178-6-26**] 04:17AM BLOOD ALT-16 AST-15 AlkPhos-56 Amylase-139*
TotBili-0.2
[**2178-6-15**] 06:40PM BLOOD Lipase-42
[**2178-6-26**] 04:17AM BLOOD Lipase-159*
[**2178-6-15**] 06:40PM BLOOD Albumin-4.1
[**2178-6-16**] 03:15PM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5*
Mg-1.9
[**2178-6-18**] 03:00AM BLOOD Triglyc-121
[**2178-6-19**] 08:59AM BLOOD Triglyc-96 HDL-20 CHOL/HD-4.8 LDLcalc-56
[**2178-6-15**] 06:42PM BLOOD Lactate-1.6
RADIOLOGY:
[**2177-6-16**] Upper GI study: Conray followed by thin barium was used
for the study. A scout view shows a drain in place over the left
upper abdomen, and surgical staples in place. There is residual
contrast within the patient's colon at the start of the study.
Contrast passes freely through the esophagus into the gastric
pouch. Contrast passes easily through the gastrojejunal
anastomosis without evidence of leak. The gastric pouch is
somewhat dilated, with an air- fluid level inside. The jejunal
loop attached to the stomach is diffusely dilated. Contrast
passes to the region of the jejunojejunal anastomosis, and then
there is complete holdup of contrast at the region of the
jejunojejunal anastomosis. The patient stood for approximately
15 minutes, and there is no further passage of contrast beyond
the level of the jejunojej. An overhead view was taken at the
conclusion of the exam.
IMPRESSION: Complete holdup of contrast at the level of the
jejunojejunal
anastomosis. The findings were discussed and the images were
reviewed with
Dr. [**Last Name (STitle) **].
[**2178-6-22**] Upper GI study: Small amount of contrast passes through
the gastrojejunal anastomosis, and there is non-passage of
contrast beyond a single jejunal loop. There is holdup of
contrast at the left lower quadrant. No evidence of leak.
[**2178-6-26**] CT Abdomen: 1. Moderate left-sided pleural effusion with
reactive atelectasis. Minimal atelectasis at the right lung
base.
2. Appropriate postoperative appearance after gastric bypass. No
evidence of obstruction
3. Two extraluminal fluid collections identified, one anteriorly
within the abdomen and the second deep within the pelvis. These
collections may be postoperative in nature, however, underlying
infection is possible.
4. Small amount of extraluminal fluid and air identified
adjacent to the
distal jejunal-jejunal anastamosis concerning for a leak. This
area may
communicate with the anterior collection described above.
[**2178-6-27**] CT Abdomen: Attempted aspiration of anterior collection.
Given the relatively high attenuation of this area, this may
rather relate to phlegmon. The small amount of material
extracted was sent for Gram stain and culture analysis.
MICRO:
[**6-15**] Blood culture: negative
[**6-26**] Blood Culture: negative
[**6-26**] Urine Culture: negative
[**6-27**] Peritoneal fluid culture: negative
Brief Hospital Course:
This is a 29 year old female who was admitted one week post-op
from a laparoscopic roux-en-y gastric bypass with severe
acute-onset abdominal pain. The patient was taken emergently to
the operating room for repair (please see the operative note of
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for full details). Post-operatively she did
well, with pain controlled with a PCA, and good pulmonary
status. She was started on parenteral nutrition which was
continued until post-op day 11. She was given post-operative
antibiotics; all cultures from her admission were negative. She
had an upper GI evaluation on post-op day 1 which demonstrated
hold-up of contrast at the anastamosis and then post-op day 7
which demonstrated improved flow of contrast through the
anastamosis. She was started on a stage 1 diet on post-op day
11. She had a CT scan on post-op day 12 which demonstrated a
pelvic and anterior fluid collection; the anterior collection
was drained by interventional radiology revealing small amounts
of lysed hematoma but no pus or infection. She was advanced to a
stage 2 and then 3 diet by post-op day 13 which she tolerated
well and her PCA was weened to oral roxicet. She was able to
ambulate on her own and her JP drain was removed on post-op day
14. She was discharged on post-op day 14 with plained follow-up
in the [**Last Name (NamePattern1) **] surgery clinic. Her staples were removed prior
to discharge and her wound remained intact and clean. All
questions were answered to her satisfaction on discharge.
Medications on Admission:
1. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2
times a day).
Disp:*600 ml* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day
for 6 months.
Disp:*360 Capsule(s)* Refills:*0*
Discharge Medications:
1. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2
times a day).
Disp:*600 ml* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day
for 6 months.
Disp:*360 Capsule(s)* Refills:*0*
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Leak at Jejunojejunostomy
Discharge Condition:
Tolerating stage 3 diet. Ambulating. Good pain control.
Discharge Instructions:
Take all medications as prescribed. Continue with your stage 3
diet. DO not drive or operate machinery while taking narcotics.
Please call the office with any worsening nausea, fevers to
101.5, or worsening abdominal pain. You should wear an abdominal
binder while in bed. You may shower and ambulate, but no baths
or heavy lifting for 3 weeks. You may continue all the
medications you were taking prior to this admission (i.e. after
your initial surgery) in addition to the medications we have
prescribed for you today.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD Where: [**Hospital6 29**] [**Hospital6 **]
SURGERY Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2178-7-1**] 2:00
Provider: [**Name10 (NameIs) **] [**Doctor Last Name 28352**], LDN Where: [**Hospital6 29**] [**Hospital6 **]
SURGERY Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2178-7-1**] 1:30
Completed by:[**2178-6-30**]
|
[
"780.6",
"998.89",
"038.9",
"997.4",
"995.91",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13",
"44.69"
] |
icd9pcs
|
[
[
[]
]
] |
8672, 8678
|
6234, 7787
|
307, 368
|
8748, 8805
|
1470, 6211
|
9374, 9791
|
8182, 8649
|
8699, 8727
|
7813, 8159
|
8829, 9351
|
1181, 1181
|
253, 269
|
396, 833
|
1195, 1451
|
855, 1024
|
1040, 1166
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,554
| 119,712
|
2155+2156
|
Discharge summary
|
report+report
|
Admission Date: [**2198-8-6**] Discharge Date:
Date of Birth: [**2130-7-25**] Sex: F
Service:
DR.[**First Name (STitle) **],[**First Name3 (LF) 125**] K. 14-118
Dictated By:[**Last Name (NamePattern1) 344**]
D: [**2198-8-15**] 10:35
T: [**2198-8-15**] 11:17
JOB#: [**Job Number 11511**]
Admission Date: [**2198-8-6**] Discharge Date: [**2198-8-15**]
Date of Birth: [**2130-7-25**] Sex: F
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 68 year-old
woman with a one week complaint of severe headache with no
aggravating or relieving factors. No history of nausea or
vomiting. The patient was alert and oriented, but
transferring physician gave [**Name Initial (PRE) **] history of visual
hallucinations. The patient had mental status changes times
one day with visual hallucinations and incontinence. The
patient was complaining of a headache and presented to [**Hospital3 6265**] where a head CT showed bleed. The patient was
transferred to [**Hospital1 69**] for
further management.
PAST MEDICAL HISTORY: Severe rheumatoid arthritis,
hypertension, and the patient has an infection of the lower
jaw for which she was receiving Augmentin and Hyperbaric O2
treatments. Gastritis, osteoporosis and gout.
ALLERGIES: Cipro and adhesive tape.
MEDICATIONS ON ADMISSION: Zantac, Decadron, Lasix, Fosamax.
PAST SURGICAL HISTORY: Cervical fusion, finger surgery,
total knee on the right times two, total hip on the right.
PHYSICAL EXAMINATION: Neurologically, alert and oriented
times two. Pupils 5 down to 3 mm, brisk. Extraocular
muscles are intact. Tongue midline. Shoulder shrug
adequate. Unable to assess motor strength and reflexes due
to the patient's joint deformities secondary to rheumatoid
arthritis. Chest clear to auscultation. Cardiac S1 and S2
are normal without murmurs, rubs or gallops. Abdomen mild
distention. No tenderness. Soft bowel sounds. Blood
pressure 178/108. Heart rate 78. Respiratory rate 20. Sats
92% on room air.
LABORATORY: White count 9.9, crit 35.3, platelet count 210,
sodium 137, K 4.1, chloride 104, CO2 23, BUN 21, creatinine
.6, glucose 150.
HOSPITAL COURSE: The patient was admitted to the Surgical
Intensive Care Unit for close monitoring. The patient was
seen by the skin specialist for severe skin tears. The
patient had Tegaderms applied, which were removed. The
wounds were cleaned with normal saline and DuoDerm wound gel
was applied with Adaptic and DSD Kling wrap with healing of
skin tears. On [**2198-8-9**] the patient underwent right frontal
craniotomy for removal of right frontal hematoma. Vital
signs have been stable. The patient was monitored in the
Surgical Intensive Care Unit. Postop she was awake and
alert. She was oriented times one with no headache, moving
all extremities in stable condition and transferred to the
regular floor on [**2198-8-12**].
The patient has remained neurologically stable. Her vital
signs have been stable and she has been afebrile. She was
seen by physical therapy and occupational therapy and found
to require placement in rehab for discharge. The patient was
seen by Plastic Surgery on the 19th who recommended
continuing Adaptic nonadhesive dressings and no surgical
debridement necessary at this time. The patient was in
stable condition with vital signs stable and she was
afebrile.
MEDICATIONS ON DISCHARGE: Dilantin 300 mg po q.h.s., Zantac
150 mg po b.i.d., Tylenol 650 po q 4 hours prn, Percocet one
to two tabs po q 4 hours prn. Miconazole powder to effected
area prn. Currently the patient is on 4 mg of Decadron po q
6 hours, which will be weaned to off over a week to ten days.
Vital signs have remained stable and the patient has been
afebrile and is being transferred to rehab in stable
condition with follow up with Dr. [**First Name (STitle) **] in the Brain [**Hospital 341**]
Clinic in one month.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2198-8-15**] 10:43
T: [**2198-8-15**] 11:18
JOB#: [**Job Number 11512**]
|
[
"401.9",
"707.8",
"V43.64",
"714.0",
"431",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
3446, 4233
|
1377, 1412
|
2225, 3419
|
1436, 1529
|
1552, 2207
|
521, 1092
|
1115, 1350
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,755
| 159,426
|
27704
|
Discharge summary
|
report
|
Admission Date: [**2132-10-18**] Discharge Date: [**2132-10-25**]
Date of Birth: [**2051-7-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
cold left foot
Major Surgical or Invasive Procedure:
Left lower extremity and bilateral pelvic arteriography of right
external iliac angioplasty and stent placement. Right to left
fem-fem bypass. Left femoral to above-knee popliteal bypass with
PTFE,
fasciotomy.
History of Present Illness:
This is an 81-year-old gentleman with
unresectable pancreatic cancer who has been developing
worsening pain of his left lower extremity over the past
several months with significant increase in severity over the
past 2 days with loss of some motor and sensory function
noted within the last day. He had a rather cyanotic foot.
Past Medical History:
1. Newly diagnosed pancreatic mass encasing the SMA and
obstructing the portal and splenic veins.
2. Status post stent placement to the common bile duct.
Brushing from the common bile duct with atypical glandular
epitheleal cells.
3. COPD on 2.5L oxygen at home.
4. Coronary artery disease.
5. Atrial fibrillation status post pacemaker placement.
6. Status post appendectomy.
Social History:
He lives with his wife, children, and grandchildren. He had
been smoking for 65 years and quit prior to his last admission.
He does not drink alcohol.
Family History:
Noncontributory.
Physical Exam:
deceased
Pertinent Results:
[**2132-10-25**] 04:00AM BLOOD
WBC-28.8*# RBC-3.37* Hgb-10.7* Hct-32.0* MCV-95 MCH-31.8
MCHC-33.5 RDW-15.3 Plt Ct-225
[**2132-10-25**] 04:00AM BLOOD
PT-15.4* PTT-25.9 INR(PT)-1.4*
[**2132-10-25**] 04:00AM BLOOD
Glucose-98 UreaN-34* Creat-1.2 Na-146* K-4.9 Cl-109* HCO3-29
AnGap-13
[**2132-10-25**] 04:00AM BLOOD
ALT-20 AST-22 AlkPhos-100 Amylase-13 TotBili-0.7
[**2132-10-25**] 04:00AM BLOOD
Albumin-2.3* Calcium-8.9 Phos-3.9 Mg-1.9
[**2132-10-25**] 11:16AM
URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.015
URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-4* pH-5.0 Leuks-TR
URINE RBC-21-50* WBC-[**12-29**]* Bacteri-FEW Yeast-NONE Epi-0-2
[**2132-10-25**] 11:18 am SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2132-10-25**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2132-10-28**]):
GRAM NEGATIVE ROD(S). MODERATE GROWTH. 2 TYPES.
STAPH AUREUS COAG +. MODERATE GROWTH.
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
FUNGAL CULTURE (Final [**2132-11-7**]):
YEAST. OF TWO COLONIAL MORPHOLOGIES.
[**2132-10-23**] 11:51 AM
CT HEAD W/O CONTRAST
FINDINGS: There is no intracranial hemorrhage. There is a
probable subacute to chronic lacunar infarct within the left
corona radiata. A second, either subacute or chronic lacunar
infarct is seen within the left lentiform nucleus. Considering
patient age, there is the expected involutional change of the
brain parenchyma identified. There is moderate atherosclerotic
calcification of the cavernous portions of both internal carotid
arteries. No overt extracranial abnormalities are discerned.
CONCLUSION: No definite evidence for acute intracranial
pathology. However, in this regard, MRI scanning with
diffusion-weighted imaging, if feasible, is a more sensitive
imaging study in the detection of acute brain ischemia.
(W/FLUORO) [**2132-10-23**] 11:00 AM
FINDINGS: Fluoroscopic examination of the patient's existing
feeding tube demonstrated the proximal portion to be coiled
within the pharynx. The distal tip was in the proximal stomach.
After unlooping the coil, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was advanced, and
despite multiple maneuvers the tube could not be advanced into
the more distal portion of the stomach. The patient's left
nostril was then anesthetized with lidocaine jelly, and a new
feeding tube was advanced into the stomach under fluoroscopic
guidance. After this was accomplished, the right-sided feeding
tube was removed. The tube was then advanced under fluoroscopic
guidance through the pylorus and into the duodenum. The tube was
positioned at the ligament of Treitz. 5 cc of contrast were
injected through the tube demonstrating appropriate positioning
with the tip in the proximal jejunum. The tube was secured with
tape.
IMPRESSION: Successful placement of nasojejunal feeding tube
under fluoroscopic guidance.
[**2132-10-24**] 3:58 AM
CHEST (PORTABLE AP).
FINDINGS: The distal tip of the enteric feeding tube is no
longer visualized. The more proximal aspect, however, takes an
expected course through the mediastinum and left upper quadrant,
consistent with placement within the gastrointestinal tract. It
is likely advanced since the comparison study. Please refer to
the portable abdominal radiograph obtained for further details.
The study is of marginal diagnostic quality for lung evaluation
secondary to respiratory motion. A large bleb is evident in the
medial right lung base. Linear atelectasis is seen in the left
lung base. Grossly, no new consolidations are identified. No
significant edema is seen. The single lead right ventricular
pacemaker is stable in course and position. Likewise, there has
been no interval change in the course or position of a right
internal jugular approach central venous catheter device.
IMPRESSION: Apparent advancement of enteric feeding tube with
distal tip not visualized on chest x-ray examination. Please
refer to abdominal x-ray for further details. Marginal
diagnostic quality of study otherwise, however, no qualitative
significant interval change
Brief Hospital Course:
pt admitted
underwent a Left lower extremity and bilateral pelvic
arteriography of right external iliac angioplasty and stent
placement. Right to left fem-fem bypass.
Left femoral to above-knee popliteal bypass with PTFE,
fasciotomy.
Post operative - respiratory distress and is intermittently
agitated and
non-verbal with decreased responsiveness, in the context of
receiving haldol, ativan and morphine for sedation
nuerology consulted - respiratory acidosis with renal
compensation / Head CT is normal
transfered to SICU for hemodynamic instability.
Family meeting held / pt with end stage pancreatic cancer
Family and hospital stay agree to let pt exoire
Pt deceased
Medications on Admission:
[**Last Name (un) 1724**]: digoxin 0.25, Megace 400", Prilosec 20, albuterol,
Combivent
Discharge Medications:
deceased
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2133-1-21**]
|
[
"427.31",
"492.8",
"444.22",
"427.5",
"445.02",
"V45.01",
"V58.61",
"157.8",
"276.2",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.18",
"00.45",
"83.14",
"00.41",
"99.60",
"39.29",
"96.6",
"39.90",
"39.50",
"96.04",
"88.48",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6995, 7034
|
6145, 6824
|
331, 542
|
7086, 7096
|
1545, 6122
|
7153, 7192
|
1483, 1501
|
6962, 6972
|
7055, 7065
|
6850, 6939
|
7120, 7130
|
1516, 1526
|
277, 293
|
570, 898
|
920, 1297
|
1313, 1467
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,698
| 170,430
|
45765
|
Discharge summary
|
report
|
Admission Date: [**2168-9-29**] Discharge Date: [**2168-10-12**]
Date of Birth: [**2084-10-17**] Sex: F
Service: MEDICINE
Allergies:
Protamine
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Upper Endoscopy [**2168-9-30**]
Colonoscopy [**2168-9-30**]
Angiography- IR guided PICC line placement and HD Line change
History of Present Illness:
In brief, Ms. [**Known lastname **] is an 83-year-old female with multiple
medical problems including ESRD on HD (MWF), DM2, PVD, Afib,
severe AS s/p mAVR (St. [**Known lastname 923**]'s valve), recurrent GIB [**2-10**]
diverticulosis s/p colectomy and [**Doctor Last Name **] procedure in [**2162**] with
continued GIBs, recently d/c'd from [**Hospital1 18**] after bleeding from
ostomy, now transfered from [**Hospital 1263**] Hospital after presenting
from rehab with approx ~1L of frank blood from ileostomy. Pt
noticed blood in ileostomy bag morning of presentation and
dropped SBPs into 80s (baseline 110-130s). Pt denies ever having
any abdominal pain, no pain around ileostomy site. Denies any
increased ileostomy output. Denies lightheadedness, weakness,
abd pain, CP, nausea, vomiting, fevers or chills.
.
Of note, most recent prior admission, pt was bleeding from
ostomy and found to have supratherapeutic INR of 6.6. After this
admission, INR goal changed to 2.5-3.0.
.
In the ED, initial VS were 98.1 84 102/52 16 100%RA. Received
3.5L NS and started receiving 1st unit PRBC. In the ED, SBPs
responded to fluids. Labs: INR 4.1, hematocrit 26.8 (similar to
baseline), plt 159. Cr 5.3 (ESRD on HD MWF, was 5.6 on [**9-13**]). GI
and colorectal surgery were consulted in the ED. VS on transfer
were 78, 115/73, 20, 98%RA.
.
During her ICU stay, pt was given 2U FFP and received 5U PRBC
total. EGD that showed gastritis, and colonoscopy that showed
diverticulosis in transverse and ascending colon, without a
specific source identified. However, likely bleed [**2-10**]
diverticuli as per GI. She was initially on protonix drip and
was later switched to daily PPIs.
.
The patient was also found to be hypocalcemic and given calcium
gluconate. Day 2 MICU patient spiked temp 101-102 and she became
hypotensive and associated AMS with hypotension, BPs minimally
responsive to 2.5 L IVF. She was started on Levo for <24hours,
she has poor peripheral access, unable to get CVL so Levo
administered through tunneled cath. Zosyn/Vanc started for
possible line infection, cultures negative and she remained
hemodynamically stable off pressors so ABx stopped, she was
given ABx for 3 days. Fever likely associated with transfusions.
AMS Required pressors <24hours. Unclear infection source,
patient Cdiff negative, blood cx still pending.
.
Upon transfer to the medicine floor, VSS with no acute bleeding.
Patient is an 83-year-old female with multiple medical problems
including ESRD on HD (MWF), DM2, PVD, Afib, severe AS s/p mAVR
(St. [**Month/Day (2) 923**]'s valve), recurrent GIB treated with colectomy and
[**Doctor Last Name **] procedure in [**2162**] with continued GIBs after the
procedures who was transferred from [**Hospital 1263**] Hospital where she
presented from rehab with approx ~1L of frank blood from
ileostomy. Patient's pressures at rehab had been SBP 110-130s
until this morning when she first noted bleeding from ostomy;
changed the bag once at 11 am. SBP reportedly dropped to 80s.
Blood has since pooled while she was in the ED. Denies
lightheadedness, weakness, abd pain, CP, nausea, vomiting,
fevers or chills.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
1. history of repeated GI bleeds: past work up revealing various
potential sources along her GI tract including small bowl AVM's,
colonic polyps, ascending and transverse colon diverticulosis.
Had L hemicolectomy with transverse colostomy and [**Doctor Last Name 3379**]
pouch in [**10/2162**] with pathology examination revealing
diverticulosis as the source of bleed.
2. Diastolic CHF (EF 65-75%) on 2L O2 at home
3. Severe AS s/p mechanical [**Year (4 digits) 1291**] [**12-14**], [**Hospital3 9642**]
4. HLD
5. ESRD on HD (MWF)
6. Hypothyroidism
7. Atrial fibrillation on amiodarone and coumadin
8. PVD
9. Diabetes Mellitus
10. HTN
11. [**2168-1-27**]: Stenting of left superficial femoral
artery/above-knee popliteal artery transition
12. [**2168-1-28**]: Left Calf Ulcer Debridement
13. [**2168-2-26**]: Left lower extremity wound debridement
14. [**2168-3-8**]: Split thickness skin graft from right thigh to left
lower calf
15. [**2168-4-19**]: left lower extremity angioplasty
16. [**2168-4-27**]: Debridement of eschar and bone from the posterior
aspect of the left heel
17. Bilateral TKR
18. Open cholecystectomy
[**76**]. ORIF right periprosthetic femur fracture with RLE plate [**2164**]
20. Left upper arm radiocephalic AV fistula [**2164**] , Left upper
arm arteriovenous graft angioplasty , L upper arm AV graft [**2165**]
Angioplasty/fistulogram [**2166**] x 5 and [**2167**] x3
Social History:
Denies tobacco, drug or illicit drug use. Discharged [**9-13**] to
rehab. Lives at home with husband and 53 year old son who
prepares her medications. Has been in the hospital or at rehab
for last 5 mos, Other sons lives in [**Name (NI) 47**] and [**Name (NI) 4565**],
daughter lives in [**Name (NI) 669**]. Pt is a retired work supervisor at
Veteran's Hospital in JP. Retired about 10 years ago.
Family History:
She is an only child. Grandfather died of cancer but son is not
sure of what type. Three sons with htn. Pt. denies any other
history of CA, DM, or HTN in her parents.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
Afebrile, Hemodynamically stable with SBPs in 120s-130s
GENERAL - well-appearing in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, Non-tender, no lymphadenopathy
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - Mechanical heart sounds heard throughout precordium.
Holosytolic murmur heard throughout precordium heard best over
apex. RRR no rubs or gallops otherwise
ABDOMEN - Obese, Ostomy bag in place with green stool free of
blood or melena evident. NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Chronic venous changes in LE bilaterally with
evidence of multiple vascular surgeries. WWP, no c/c/e, 2+
peripheral pulses. She has evidence of a RUE hand tremor
SKIN - no rashes or lesions other than chronic changes
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission Labs:
[**2168-9-29**] 07:40PM BLOOD WBC-3.7* RBC-3.13* Hgb-8.9* Hct-26.8*
MCV-86 MCH-28.5 MCHC-33.2 RDW-17.4* Plt Ct-159
[**2168-9-29**] 07:40PM BLOOD Neuts-41.5* Lymphs-48.9* Monos-5.3
Eos-3.7 Baso-0.5
[**2168-9-29**] 07:40PM BLOOD PT-40.1* PTT-32.7 INR(PT)-4.1*
[**2168-9-29**] 07:40PM BLOOD Glucose-97 UreaN-32* Creat-5.3* Na-135
K-4.4 Cl-101 HCO3-27 AnGap-11
[**2168-9-29**] 11:14PM BLOOD Calcium-7.5* Phos-3.3 Mg-1.8
BCx Negative x2
C.Diff Toxin negative x2
[**2168-9-30**] Colonoscopy: Multiple non-bleeding diverticula with
mixed openings were seen in the transverse colon and ascending
colon. Diverticulosis appeared to be of moderate severity.
Throughout the colon red flecks consistent with old blood was
noted in the colon.
Impression: Diverticulosis of the transverse colon and ascending
colon
Otherwise normal colonoscopy to cecum
[**2168-9-30**] EGD: Normal mucosa in the whole esophagus
Erythema in the whole stomach compatible with gastritis
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Discharge Labs:
[**2168-10-12**] 07:50AM BLOOD WBC-3.4* RBC-2.54* Hgb-7.4* Hct-23.8*
MCV-94 MCH-29.0 MCHC-30.9* RDW-17.0* Plt Ct-182
[**2168-10-12**] 07:50AM BLOOD PT-21.4* PTT-116.6* INR(PT)-2.0*
[**2168-10-12**] 08:32AM BLOOD Glucose-84 UreaN-38* Creat-3.0*# Na-136
K-4.5 Cl-101 HCO3-26 AnGap-14
[**2168-10-12**] 08:32AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.0
INR Trend
[**2168-10-12**] 07:50AM BLOOD PT-21.4* PTT-116.6* INR(PT)-2.0*
[**2168-10-11**] 09:00AM BLOOD PT-18.8* PTT-79.7* INR(PT)-1.7*
[**2168-10-11**] 06:40AM BLOOD PT-18.4* PTT-83.5* INR(PT)-1.6*
[**2168-10-10**] 05:50AM BLOOD PT-15.6* INR(PT)-1.4*
[**2168-10-9**] 06:38AM BLOOD PT-13.5* PTT-72.6* INR(PT)-1.2*
[**2168-10-7**] 05:46AM BLOOD PT-13.3 PTT-67.4* INR(PT)-1.1
Labs of Note:
[**2168-10-11**] 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
HBV Viral Load Pending
Brief Hospital Course:
83 year old female with multiple medical problems including ESRD
on HD (MWF), DM2, PVD, Afib, severe AS s/p mAVR (St. [**Month/Day/Year 923**]'s
valve), multiple GIB treated with colectomy and [**Doctor Last Name **]
procedure in [**2162**], continued GIBs after the procedures now
presents with bleeding from ileostomy.Colonoscopy and EGD showed
no active bleeding but evidence of diverticulosis and evidence
of prior GIB.
#. GI bleed: Resolved, most likely diverticular in origin
considering significant past history of diverticular bleeds and
evidence on colonoscopies. Each of these past bleeds have
occurred in the setting of supratherapeutic INRs, consistent
with this admission. Stable Hct and no GI complaints. Patient
requires a total colectomy for definative treatment of her
recurrent bleeds, though patient does not want surgery because
complicated post-op course last time. Her Coumadin appears to be
therapeutic when she is at home but at rehab center she became
supratherapeutic. She will likely benefit long term from having
a home INR monitor to prevent future episodes. GIB did not recur
after Coumadin/Heparin bridge was started. Her Hct trended down
to 23.8 on discharge without gross bleeding. This information
was shared with the accepting physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12879**], at [**Hospital 100**]
Rehab MACU where they will monitor her Hct and potentially
provide transfusions as needed.
#. Subtherapeutic INR: Patient continued to be subtherapeutic
despite titrating up Coumadin to 10mg Daily. Her INR started
uptrending after 10mg were given and she was tapered down to
7.5mg and down again to 4mg on day of discharge when her INR was
2.0. Likely related to large doses of Vitmain K given in MICU.
Given active bleeding and concern for hemodynamic instability
for now will aim for lower end of therapeutic range (goal INR
2.5-3.0). Heparin drip should be continued until she is
therapeutic. Discharged on Coumadin 4mg home dose.
#. Hypotension and Fever: Septic etiology was entertained
initially in MICU. The patient was started on ceftazidime and
vancomycin. This was discontinued in MICU prior to transfer to
floor. The patient was also worked up for Clostridium difficile
infection, despite her lack of diarrhea. Patient was started on
empiric P.o. Flagyl, this was also discontinued. Pt's blood
culture and C.diff screening remained negative. This was most
likely tranfusion related rather than an active infection as
fever/hypotension occured following 5 units PRBCs and 2 units
FFP.
#. [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] mechanical aortic valve: Given the concern for
active hemorrhage, we were judicious with the use of heparin.
The patient initially came in supratherapeutic, and throughout
her stay her INR is monitored. After Coumadin was held some time
her INR became sub-therapeutic and she was bridged to Heparin
(see above).
# Thrombocytopenia: Her platelets downtrended during her stay
but stablizes around 112. Uunclear etiology, ddx abx related vs
consumptive. low suspicion for HIT. It was monitored and she
continued uptrending after transfer out of MICU.
#. Goals of Care: She was seen by Palliative Care during
hospitalization. Patient aware of her prognosis but enjoys
living and expects to live past her 84th birthday. Pal Care
initiated conversations which can be addressed again in the
future but for now she remains FC. Pal care continues to follow.
CHRONIC STABLE CONDITIONS:
#. ESRD on HD: No urgent indication for HD. The patient was
continued on a regular hemodialysis schedule. Her dialysis
access was used to draw laboratory tests, and infuse
antibiotics.
#. Afib: In sinus rhythm during admission. Continue amiodarone.
#. Hypothyroidism: Continued levothyroxine.
#. Hyperlipidemia: Continued pravastatin.
#. DM: HISS
#. Diastolic Heart Failure: Chronic, well compensated. Last Echo
[**2165**] LVEF >55% on 2L NC home O2. Continued Oxygen and home meds.
#. FEN: PRBC transfusion prn, replete lytes prn, NPO for now
Transitional Issues:
- Continue Heparin Drip until INR becomes therapeutic
- Monitor Hct as she has had borderline low Hct and has a
history of GIBs. She has not had any melena or BRB per ostomy.
She has not required PRBCs since transfer out of MICU.
- She should be set up with a home INR monitor to prevent future
admissions for GIBs
- Goals of Care discussion was initiated by our Palliative Care
department. She remains full code which has been confirmed with
family and outpatient providers. If she is hospitalized again
for GIB and requires significant resucitation this should be
readdressed.
- Of note she had hepatitis panel and HIV drawn because an
interventional radiologist had a needle stick during procedure.
HbSAg and HbCAg were positive, HBV viral load still pending on
discharge. HIV never came back but patient was consented by
blood bank.
- PICC line is not completely central but is superior to SVC and
so is okay to use for labs and heparin drip. Angio tried to
advance but she has some subclavian stenosis and so unable.
Medications on Admission:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY
5. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous
ASDIR (AS DIRECTED): As per sliding scale.
6. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS
7. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. insulin lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): Continue to use your home
Insulin Sliding Scale as prescribed.
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Coumadin dosing should be titrated by your [**Hospital 197**] Clinic
for an INR goal 2.5-3.5.
10. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Six [**Age over 90 1230**]y (650) units Intravenous QHR:
Please continue Heparin Drip until INR therapeutic (2.5-3.5).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Active:
- GI Bleed
- Diverticulosis
Chronic:
- Chronic Diastolic Heart Failure (LVEF >55%)
- Severe Aortic Stenosis s/p St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**]
- HLD
- ESRD on HD (MWF)
- Hypothyroidism
- A.Fib on Amiodarone
- Diabetes Mellitus
- HTN
- PVD s/p multiple vascular surgeries
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure treating you during your hospitalization. You
were admitted to [**Hospital1 18**] with a GI bleed requiring MICU stay. In
the MICU you were stabilized with IVFs and you received 5 units
of Packed Red Blood Cells and 2 units of Fresh Frozen Plasma.
Your Coumadin was held and you received 2 doses of Vitamin K to
reverse the anticoagulation. Upper and lower endoscopies
revealed gastritis and diverticulosis. Your bleed stopped and
when hemodynamically stable you were transferred to the general
medicine floor. On the floor you were hemodynamically stable and
did not have anymore GIBs. You had an interventional radiology
guided PICC line placement and HD line change. Your Coumadin was
restarted, you were bridged with Heparin drip and you were
discharged with an INR of 2.0(goal 2.5-3.5). You were discharged
in stable condition without anymore GIBs.
Medication Changes:
- CONTINUE Coumadin at your 4mg QDaily home dose
- Please continue to take your medications as prescribed
- Heparin Drip per weight based protocol. Continue Heparin drip
until patient INR therapeutic 2.5-3.5
Discharge Instructions
- Please monitor INR daily until she is therapeutic
- Please provide patient with a home INR monitor so she can more
closely titrate Coumadin doses. She has had recurrent GIBs
requiring hospitalization for periods of supratherapeutic INR.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 608**]
*Your primary care physician will be following up with you at
your home within 3 days.
|
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32,288
| 118,560
|
33097
|
Discharge summary
|
report
|
Admission Date: [**2165-3-4**] Discharge Date: [**2165-3-18**]
Date of Birth: [**2086-1-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
cARDIAC CATHETER
MV repair (27mm band) preop IABP
History of Present Illness:
79 year old male w/ a h/o htn, hyperlipidemia, MVP and 2+ MR
diagnosed 2 years ago who was admitted to [**Hospital1 **] on [**2-28**] with
severe shortness of breath. At the time of presentation, he was
found to have a loud murmur and an [**Month/Day (4) 113**] was repeated on [**2165-3-1**]
which showed worsening of his MR to 4+ with a new flail leaflet.
He was also noted to have 3+ TR with severe pulmonary
hypertension. The estimated peak pulmonary pressure of 100 mmHg.
EF was 65%. Of note, he had fallen at home sometime prior to
admission and was c/o neck pain upon presentation. A C spine was
done which was negative.
.
Patient was admitted to the ICU. He ruled out for MI with
serial
cardiac enzymes. He had no ischemic ECG changes. He was treated
with diuretics, beta blockers, and ace inhibitors without
significant improvement per her his physicians at the OSH. He
remained hemodynamically stable with O2 sats in the high 90's on
4LNC and had no objective evidence of respiratory distress. He
did complain of cough at the OSH and was started on levaquin for
empiric coverage but there was no evidence of infiltrate on
repeated CXRs. All culture data was negative and he remained
afebrile. He had an elevated d dimer at the OSH and had a CTA
chest performed which was negative for PE. He was transferred to
[**Hospital1 18**] for diagnostic catheterization and surgical evaluation.
.
In the 24 hours prior to transfer, patient became more confused
thought possibly related to ETOH withdrawal vs. low cardiac
output. He was given a dose of ativan at 11am on [**3-4**]. Patient
son notes that he is mildly confused at baseline but is more
confused than his baseline currently. The son also notes
significant daily EtOH history.
.
Upon arrival to [**Hospital1 18**], patient is awake, alert, and cooperative.
He is oriented x1. He does note some shortness of breath but is
otherwise without complaint. History is limited due to
confusion
but he denies any recent chest pain, fevers, chills,
nightsweats,
or any other new complaints. He was taken directly to the cath
lab for RHC which showed elevated right and left sided filling
pressures. LHC showed non-obstructive CAD. An IABP was placed
and
he was transferred to the CCU.
Past Medical History:
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: No prior h/o CABG, PCI, or EPS
.
Other Past Medical History:
# MVP w/ mitral regurgitation dx'ed 2 years ago
# h/o diverticulitis
# h/o nephrolithiasis
Social History:
Social history is significant for the [**4-2**] EtOH drinks per day
per
patient's son. [**Name (NI) **] tobacco in over 30 years. He currently lives
in
Tauton with his wife. Family history is noncontributory at this
time.
Family History:
NOT OBTAINED
Physical Exam:
VS: T 97.6, BP 93/49, HR 74, RR 20, O2 98% on RA
Gen: WDWN elderly aged male breathing comfortably.
Neuro: A+Ox3. No significant resting or intention tremor. Moves
all extremities. Follows simple commands. Answers questions.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple. Thick neck. Cannot appreciate JVP.
CV: Prominent PVI visible in midclavicular line. Regular,
tachycardic. Normal S1, S2. No S4, no S3.
heard throughout precordium w/ palpable thrill at apex.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar rales. No
wheezes or rhonchi. Strenal inc c/d/i.
Abd: soft, NTTP, No abdominial bruits, No CVA tenderness
Ext: No c/c/e. Palp distal pulses
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2165-3-16**] 09:40AM BLOOD
WBC-9.0 RBC-3.49* Hgb-11.1* Hct-33.0* MCV-94 MCH-31.8 MCHC-33.7
RDW-14.0 Plt Ct-614*
[**2165-3-18**] 07:20AM BLOOD
PT-14.7* INR(PT)-1.3*
[**2165-3-16**] 09:40AM BLOOD
Glucose-177* UreaN-21* Creat-1.0 Na-140 K-4.4 Cl-100 HCO3-33*
AnGap-11
[**2165-3-16**] 09:40AM BLOOD
Calcium-8.3* Phos-3.4 Mg-2.1
[**2165-3-6**] 04:08PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
URINE RBC->50 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-<1
[**2165-3-14**] 8:26 AM
CHEST (PORTABLE AP)
INDICATION: Pleural effusion assessment.
Small left pleural effusion has slightly increased in size with
adjacent worsening atelectasis at the left lung base. Small
right pleural effusion is unchanged. The remainder of the exam
is also without change
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 39% >= 55%
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Marked LA enlargement. No spontaneous [**Hospital1 113**] contrast
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Top normal/borderline
dilated LV cavity size. Moderately depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Mild to moderate ([**1-30**]+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Elongated mitral valve leaflets. Moderate/severe MVP. Partial
mitral leaflet flail. Eccentric MR jet. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
The left atrium is markedly dilated. No spontaneous [**Month/Day (2) 113**]
contrast is seen in the body of the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= 30-40%). The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Mild to
moderate ([**1-30**]+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. The mitral valve leaflets are
elongated. There is moderate/severe mitral valve prolapse. There
is partial mitral leaflet flail. An eccentric, XXX directed jet
of Severe (4+) mitral regurgitation is seen.
POST CPB:
1. Posterior annuloplasty ring in mitral position. Well seated
and stable.
2. No evidence of dynamoc LVOT obstruction.
3. MVA by PHT = 2.5 cm2.
5. Mean Gradient acorss mitral vlave = 2 mm Hg
6. Improved RV systolic function with inotropic support.
7. Improved LV systolic function
Brief Hospital Course:
Pt admitted for SOB
.
Transfer4ed to CCU for primary care.
.
INITIAL CARE PER CCU TEAM / PLEASE SEE BELOW FOR HOSPITAL
COURSE:
.
Pump: new 4+ MR [**First Name (Titles) **] [**Last Name (Titles) **] from OSH. Ddx would include myxomatous
degeneration, infection, trauma, or ischemia. Given h/o MVP and
advanced age, suspect myxomatous disease. Ruled out for MI at
OSH although could have been due to prior event. No evidence of
infection on hx or exam. RHC showed cardiogenic shock. AIBP
placed.
- AIBP
- check CXR for line placement
- follow peripheral pulses
- heparin gtt while on AIBP
- diuresis w/ lasix bolus +/- gtt
- check [**Last Name (Titles) **] here
.
# CAD/Ischemia: ruled out for MI. No h/o ischemia but limited
due
to patient's mental status.
- asa, statin
- on heparin gtt given IABP
- follow ECGs
.
# Rhythm: sinus tach currently. Potentially for CO augmentation
vs. [**3-2**] EtOH withdrawal.
- beta blocker low dose, titrated while in hospital
- treat withdrawal as below
.
# MS changes: ddx includes EtOH withdrawal, ICH, delerium,
infxn.
No e/o infxn at OSH w/ negative cxs. Leukocytosis currently but
could be stress demargination.
- treat EtOH withdrawal as below
- follow resp status
- CT head neg
- panculture for possible infectious etiology: blood cxs, U/A
and
cx, CXR, and sputum cx, r/o for infection.
.
# EtOH abuse: h/o [**4-2**] drinks/day according. Tachycardia and
confusion on exam and onset 72 hours after admission.
- [**Month/Day (3) 76931**] CIWA protocol
- thiamine, folate, MVI
.
# Pulm: no e/o infection at OSH but treated w/ levaquin.
- cont abx for now
- check CXR here w/ sputum cxs
- follow resp status given severe MR [**First Name (Titles) **] [**Last Name (Titles) **] requirements. If
ABGs worsening, would electively intubate
- alb/atrovent nebs
.
# s/p fall: c/o back pain at OSH following recent fall. Other
events surrounding fall unknown. No complaints currently.
C-spine
negative at OSH. Neuro exam nonfocal.
- CT head negative
.
# Prophylaxis: heparin gtt. Cont PPI. Colace/senna.
.
.
# Disp: for MVR
.
HOSPITAL COURSE:
Cardiac Surgery consulted.
Pt improved on IABP / CT scan was done because of the confusion
/ Pt r/o out for stroke. Pt pre-oped for surgery. ASA was
decresed to 81 qd, in preperation of surgery
[**2165-3-6**]
dental and anesthesia consult obtained for preperation os
surgery
[**2165-3-7**]
PREOPERATIVE DIAGNOSIS: Cardiogenic shock, severe mitral
regurgitation, flail posterior leaflet.
OPERATION: Emergent mitral valve repair with a quadrangular
resection of the posterior leaflet of the mitral valve vein and
a 29 mm Duran annuloplasty band.
PT TOLERATED THE PROCEDURE WELL NO COMPLICATIONS. HE WAS
TRANSFERED TO CVICU FOR FURTHER POST OPERATIVE CARE.
[**2165-3-8**]
lasix was held for low BP, Cipro continued for bronchitis, epi
was weaned, when weaned IABP was removed. No sequle from balloon
pump removal.
[**2165-3-9**]
unable to wean vent, lasix started, BP improved - diuresis
[**2165-3-10**]
CT removed, post cxr lung stable, nitro weaned, Pt transfused
one unit of PRBC for low HCT
[**2165-3-11**]
sedation weaned, vent weaned / extubated, lasix continued for
one liter negative, Epicardial wires removed, pt tolerating BB,
CIWA protocol
Cipro DC for bronchitis
[**2165-3-12**]
narcotics minimized for confusion, Tylenol prn, Lopressor
increased, s[peech and swallow for prolong intubation - passed,
Thiamine, folate. MVI started, CIWA scale continued, pt
transfered to the floor
[**2165-3-13**]
pt evaluation, lopressor ioncreased, lytes followed and
repetede, bowel regime initiated.
[**2165-3-14**]
pt requires sitter, OOB, ambulation began. c/w diuresis, B
Blockade increased
[**2165-3-15**]
pt experiences afib, amio started, afib lasted more then 24 hrs,
coumadin started, INR followed
[**3-16**] - [**3-18**]
pt stable, required sitter at night, INR followed .B-Blockade,
amio taper, diuresis continued.
ON DC pt with out sitter x 24 hrs
INR 1.3 on DC
[**2165-3-11**]
Medications on Admission:
meds on transfer Lipitor 20', ASA 325', captopril 12.5'", lasix
20", levaquin 550"", lopressor "", protonix 40'
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Moniter INR goal is [**3-3**]. AFIB. Tablet(s)
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed.
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): TAPER AS FOLLOWS:
400 [**Hospital1 **] x 3 days, then
200 TID x 7 days, then
200 [**Hospital1 **] x 7 days
then 200 qd.
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
18. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day: while on
lasix.
19. INSULIN
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-60 mg/dL 4 oz. Juice 4 oz.
61-109 mg/dL 0 Units 0 Units 0 Units 0 Units
110-130 mg/dL 2 Units 2 Units 2 Units 0 Units
131-150 mg/dL 4 Units 4 Units 4 Units 0 Units
151-180 mg/dL 6 Units 6 Units 6 Units 2 Units
181-210 mg/dL 8 Units 8 Units 8 Units 4 Units
211-240 mg/dL 10 Units 10 Units 10 Units 6 Units
> 240 mg/dL Notify M.D.
20. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO QID PRN: FOR
sbp GREATER THEN 140.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34165**] - [**Location (un) 2498**]
Discharge Diagnosis:
CAD
Post operative confusion
AFIB
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Please shower daily.
No bathing or swimming for 1 month. Use sunscreen on incision if
exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
[**Last Name (LF) **],[**First Name3 (LF) 12562**] [**Telephone/Fax (1) 62076**], 1-2 weeks
FOLLOW UP WITH DR [**Last Name (STitle) **] IN 3 WEEKS
Completed by:[**2165-3-18**]
|
[
"518.81",
"428.40",
"272.4",
"416.8",
"458.29",
"490",
"427.89",
"303.90",
"424.1",
"786.3",
"785.51",
"V15.82",
"293.9",
"285.9",
"427.31",
"291.81",
"440.0",
"723.1",
"401.9",
"780.97",
"428.0",
"414.01",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.21",
"39.64",
"39.61",
"37.61",
"35.12",
"96.71",
"88.56",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14614, 14693
|
8151, 10214
|
339, 391
|
14771, 14778
|
4143, 7829
|
15493, 15672
|
3166, 3180
|
12313, 14591
|
14714, 14750
|
12177, 12290
|
10232, 12151
|
14802, 15470
|
3195, 4124
|
280, 301
|
419, 2667
|
2818, 2910
|
2926, 3150
|
7840, 8128
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,369
| 150,280
|
40432
|
Discharge summary
|
report
|
Admission Date: [**2134-4-26**] Discharge Date: [**2134-5-12**]
Date of Birth: [**2074-4-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
cardiac work up preop Right CEA
Major Surgical or Invasive Procedure:
[**2134-4-26**]
1. Off-pump coronary artery bypass graft times 4: Left
internal mammary artery to left anterior descending
artery and saphenous vein grafts to diagonal, obtuse
marginal and posterior descending arteries.
2. Endoscopic harvesting of the long saphenous vein.
[**2134-4-26**]
Re-exploration for bleeding after coronary artery
bypass grafting
[**2134-5-11**]
TEE
Cardioversion
History of Present Illness:
59 year old male with a history of
cerebral vascular accident 5-6 years ago with no residual
defecit, carotid artery disease -in which he has been followed
by
a vascular surgeon at OSH after a " stroke" 5 years ago that
manifested as confusion, without weakness, dysarthria or visual
symptoms. His stenosis is reportedly 50-60% but on recent
Opthalmic exam he was noted to have areas on right eye exam c/w
with emboli and thus was scheduled for CEA. As per patient he
denies amaurosis fugax, weakness or any neurologic symptoms. He
is undergoing cardiac work up preoperatively for his scheduled
carotid endarterectomy with his vascular surgeon, Dr.[**First Name (STitle) 10378**] at
GSH. Preoperative Persantine stress test demonstrated a 70 pt
blood pressure decline 172/106 to 100/60. No anginal chest pain
was noted. No diagnostic ST T wave changes noted w occasional
supraventricular and ventricular premature beats noted. Nuclear
imaging revealed a predominantly fixed inferior wall defect with
some reversibility; EF 37% with apical and lateral hypokinesis.
he was referred for cardiac catheterization which demonstrates
severe 3 vessel disease. Cardiac surgery was consulted for
revascularization.
Past Medical History:
Coronary Artery Disease, s/p CABG
PMH:
IDDM,CVA with no residual
Hyperlipidemia,Right carotid stenosis,Diabetic neuropathy
Right foot diabetic ulcer/infection ,PVD
PSH:
angioplasty on left leg at [**Hospital3 417**] 1.5 yrs ago,
Appendectomy, Right 2nd toe amputation
Social History:
Lives with:Married with 2 sons. Owns a freight company that
sends fresh seafood.
Contact for discharge: Wife cell [**Telephone/Fax (1) 88613**]
[**Name2 (NI) 1139**]: NO
ETOH: NO
Family History:
non-contributory
Physical Exam:
Pulse:77 Resp:24 O2 sat:
B/P 157/77
Height: 6 feet
Weight: 240 lbs
General:pleasant, A&Ox3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] well healed (R)LQ open-appendectomy scar
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x] (R)foot ulcer->per pt,improving->now off ABX
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:@+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit (L) noted/ (R)not appreciated, pulses 2+ (B)
Pertinent Results:
TEE Intra-op [**2134-4-26**]
Conclusions
PRE OFF PUMP GRAFTING
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. There is mild to moderate
regional left ventricular systolic dysfunction with akinesis of
the inferior base and severe hypokinesis of the mid to distal
lateral and anterolateral walls.. Overall left ventricular
systolic function is mild to moderately depressed (LVEF= 40 %).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen.
DURING positioning of the heart for grafting there was moderate
MR
POST GRAFTING
There is improvement of the lateral wall. LVEF~ 40%. The MR [**First Name (Titles) **] [**Last Name (Titles) 38154**]d. The remaining study is unchanged.
[**2134-5-11**] 05:00AM BLOOD WBC-8.3 RBC-3.26* Hgb-9.8* Hct-31.5*
MCV-97 MCH-30.0 MCHC-31.1 RDW-14.7 Plt Ct-521*
[**2134-5-10**] 08:34AM BLOOD WBC-12.1* RBC-3.64* Hgb-10.7* Hct-34.0*
MCV-94 MCH-29.5 MCHC-31.5 RDW-14.9 Plt Ct-573*
[**2134-5-11**] 05:00AM BLOOD PT-27.3* INR(PT)-2.6*
[**2134-5-10**] 08:34AM BLOOD PT-25.1* INR(PT)-2.4*
[**2134-5-9**] 05:12AM BLOOD PT-23.7* PTT-26.4 INR(PT)-2.2*
[**2134-5-8**] 05:03AM BLOOD PT-23.6* INR(PT)-2.2*
[**2134-5-7**] 04:01AM BLOOD PT-19.5* INR(PT)-1.8*
[**2134-5-6**] 05:01AM BLOOD PT-16.7* PTT-21.5* INR(PT)-1.5*
[**2134-5-5**] 08:40AM BLOOD PT-14.2* INR(PT)-1.2*
[**2134-5-4**] 02:48AM BLOOD PT-12.3 PTT-19.6* INR(PT)-1.0
[**2134-5-11**] 05:00AM BLOOD Glucose-183* UreaN-36* Creat-1.5* Na-138
K-4.2 Cl-102 HCO3-24 AnGap-16
[**2134-5-10**] 08:34AM BLOOD Glucose-177* UreaN-36* Creat-1.5* Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
Brief Hospital Course:
The patient was brought to the Operating Room on [**2134-4-26**] where
the patient underwent CABG x 4 with Dr. [**First Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. The patient was hemodynamically labile
post-operatively. He returned to the OR on POD 1 to be
re-explored for bleeding. Bleeding was noted from a side branch
of the LIMA. The patient returned to the CVICU for invasive
monitoring and recovery. Over the next 5 days, pressors were
weaned, diuresis initiated and the patient was extubated. Beta
Blocker was initiated. He did develop Atrial Fibrillation.
Beta blocker was titrated, and amio added. He was started on
coumadin. He was cardioverted to SR on [**4-28**], but would
subsequently return to atrial fibrillation. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
He developed diarrhea, and Flagyl was started empirically while
C-Diff was pending. CDiff toxin would return negative, and the
patient was treated with Lomotil.
Atrial Fibrillation persisted. He had a TEE which revealed no
clot, and was successfully cardioverted to SR again on [**2134-5-11**].
The patient was evaluated by the physical therapy service for
assistance with strength and mobility.
By the time of discharge the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home in good condition with
appropriate follow up instructions.
Medications on Admission:
Cilostazol 100 mg", Plavix 75mg', Gabapentin 600",
Gabapentin 600mg", Novolog 70/30 40 units in the am, 20 units in
the pm, Simvastatin 20 mg ', Asa 325mg'
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR 2.0-2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 29247**] [**Telephone/Fax (1) 29248**]
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. cilostazol 100 mg Tablet Sig: One (1) Tablet PO daily ().
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): decrease to 400mg daily on [**2134-5-19**] then as directed.
Disp:*120 Tablet(s)* Refills:*2*
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
10. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day:
indication afib
INR goal 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*2*
11. novolog 70/30
40 units every morning and
20 units every evening
Discharge Disposition:
Home with Service
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Coronary Artery Disease, s/p CABG
PMH:
IDDM,CVA with no residual
Hyperlipidemia,Right carotid stenosis,Diabetic neuropathy
Right foot diabetic ulcer/infection ,PVD
PSH:
angioplasty on left leg at [**Hospital3 417**] 1.5 yrs ago,
Appendectomy, Right 2nd toe amputation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr.[**First Name (STitle) **] [**Telephone/Fax (1) 170**], [**2134-5-31**] 2:00pm in the [**Hospital **]
Medical office building
Cardiologist Dr. [**Last Name (STitle) 7047**] on [**6-25**] at 1:20pm
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 29248**] in [**3-9**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for atrial fibrillation
Goal INR 2.0-2.5
First draw [**2134-5-13**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 29247**] [**Telephone/Fax (1) 29248**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2134-5-21**]
|
[
"V12.54",
"433.10",
"997.1",
"348.30",
"357.2",
"V58.67",
"443.9",
"V45.85",
"998.11",
"285.1",
"272.4",
"787.91",
"250.60",
"427.31",
"E878.2",
"511.9",
"458.29",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"38.91",
"36.99",
"99.62",
"88.72",
"36.15",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
8301, 8377
|
5116, 6756
|
341, 746
|
8690, 8858
|
3251, 5093
|
9646, 10598
|
2491, 2509
|
6963, 8278
|
8398, 8669
|
6782, 6940
|
8882, 9623
|
2524, 3232
|
269, 303
|
774, 1985
|
2007, 2278
|
2294, 2475
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,813
| 161,031
|
26696
|
Discharge summary
|
report
|
Admission Date: [**2136-7-30**] Discharge Date: [**2136-8-5**]
Date of Birth: [**2087-3-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft X 4 (LIMA to LAD, SVG to Diag, SVG
to OM, SVG to RCA) on [**2136-7-30**]
History of Present Illness:
This is a 49-year-old female who has a history of known CAD s/p
PCI of the RCA and the LCx in [**2135-12-13**]. She reports that
she has been feeling well since her last cardiac catheterization
in [**Month (only) **], until two months ago. In [**2136-5-12**] she began
developing symptoms that were similar to what she was
experiencing prior to her last cardiac catheterization. She
describes these symptoms, as chest pains that radiate to her
throat and jaw and are associated with shortness of breath. She
went to see her cardiologist who referred her for a repeat
cardiac catheterization to further evaluate her symptoms. Cath
revealed significant three vessel disease with in-stent
restenosis. She was thus referred for surgical intervention.
Past Medical History:
Coronary Artery Disease s/p PCI of the proximal LCx and mid RCA
in [**2135-12-13**], Hypertension, Hyperlipidemia, Obesity,
Schwannoma tumor, Asthma, Gastroesophageal Refulx Disease, s/p
Tubal Ligation approximately 20 years ago
Social History:
Patient is divorced with two adult children. She currently works
as a sales associate for [**Company 39532**]. Denies Tobacco. Patient
states that she rarely drinks alcoholic beverages. She denies
the use of recreational drugs.
Family History:
Patient reports that her younger brother had one stent placed at
the age of 40. Her sister has had two stents placed at the age
of 52. Her father passed away at the age of 60 from "heart
problems." [**Name2 (NI) **] [**Name2 (NI) 1834**] a CABG in [**2111**].
Physical Exam:
VS: 87 124/78 64" 171#
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, -edema
Neuro: MAE, Non-focal, A&O x 3
Pertinent Results:
Echo [**7-30**]: Prebypass: There is mild symmetric left ventricular
hypertrophy. There is mild regional left ventricular systolic
dysfunction. Overall left ventricular systolic function is
mildly depressed. Resting regional wall motion abnormalities
include mildly depressed mid and apical portions of the inferior
wall. There are simple atheroma in the descending thoracic
aorta. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The right coronary stent is seen
protruding into the aorta about 1 cm above the aortic valve. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**2-13**]+) mitral regurgitation is seen. Chordal [**Male First Name (un) **] seen. Post
Bypass: Biventricular systolic function remains unchanged. Mild
mitral regurgitation persists.
CXR [**8-4**]: PA and lateral radiographs of the chest demonstrate
interval removal of the right internal jugular introducer seen
on [**2136-8-2**]. No pneumothorax. The cardiomediastinal contours
are unchanged. Patient is again noted to be status post median
sternotomy. No effusion. There may be mild left basilar
atelectasis, improved when compared to the previous exam. Mild
right basilar atelectasis persists. Trachea is midline.
[**2136-7-30**] 11:24AM BLOOD WBC-28.7*# RBC-3.71* Hgb-9.0* Hct-27.0*
MCV-73* MCH-24.3* MCHC-33.3 RDW-20.4* Plt Ct-313
[**2136-7-30**] 12:33PM BLOOD WBC-28.7* RBC-3.34* Hgb-8.1* Hct-24.1*
MCV-72* MCH-24.2* MCHC-33.5 RDW-20.4* Plt Ct-347
[**2136-8-1**] 02:00AM BLOOD WBC-18.2* RBC-3.32* Hgb-9.3* Hct-25.7*
MCV-77* MCH-28.1 MCHC-36.3* RDW-18.3* Plt Ct-170
[**2136-8-3**] 02:58PM BLOOD WBC-16.0* RBC-3.70* Hgb-10.5* Hct-29.7*
MCV-80* MCH-28.4 MCHC-35.4* RDW-18.4* Plt Ct-347
[**2136-7-30**] 11:24AM BLOOD PT-14.6* PTT-29.5 INR(PT)-1.3*
[**2136-8-2**] 02:18AM BLOOD PT-12.2 PTT-28.2 INR(PT)-1.0
[**2136-7-30**] 12:33PM BLOOD UreaN-11 Creat-0.5 Cl-109* HCO3-24
[**2136-8-3**] 02:58PM BLOOD Glucose-107* UreaN-17 Creat-0.6 Na-138
K-3.9 Cl-98 HCO3-30 AnGap-14
[**2136-8-3**] 02:58PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
Brief Hospital Course:
As mention in the HPI, Ms. [**Known lastname **] [**Last Name (Titles) 1834**] cardiac cath on
[**7-24**] where she was found to have severe three vessel disease.
She was discharged home after cath and returned to [**Hospital1 18**] on [**7-30**]
for same day admit. On this day she was brought to the operating
room where she [**Month/Year (2) 1834**] a coronary artery bypass graft x 4.
Please see operative report for surgical details. She tolerated
the procedure well and was transferred to the CSRU for invasive
monitoring in stable condition. While in the CSRU she continued
to have ongoing bleeding in her chest tubes (approx. 200 cc/hr)
despite platelets, pRBC and aprotinin. She was later brought
back to the operating room for exploration. After re-op she was
again transferred back to the CSRU. She remained intubated until
post-op day one where she was weaned from sedation, awoke
neurologically intact and extubated. Beta blockers and diuretics
were started and she was gently diuresed towards her pre-op
weight. Chest tubes and epicardial pacing wires were removed on
post-op day three. She was transferred to the telemetry floor on
post-op day four. She continued to make steady improvements and
appeared to be doing well with stable labs and vitals signs on
post-op day six. She was thus discharged home with VNA services
and the appropriate follow-up appointments.
Medications on Admission:
Plavix 75mg daily every morning
Aspirin 325mg daily every morning
Lisinopril 5 mg daily every morning
Toprol XL 50mg daily every morning
Lipitor 20 mg daily every morning
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*1 MDI* Refills:*2*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary ARtery Bypass Graft x 4
PMH: s/p PCI of the proximal LCx and mid RCA in [**2135-12-13**],
Hypertension, Hyperlipidemia, Obesity, Schwannoma tumor, Asthma,
Gastroesophageal Refulx Disease, s/p Tubal Ligation
approximately 20 years ago
Discharge Condition:
good
Discharge Instructions:
no lifting > 10 # for 10 weeks
may shower, no bathing or swimming for 1 month
no driving for 1 month
Followup Instructions:
with Dr.[**Last Name (STitle) **] in [**4-14**] weeks
with Dr. [**Last Name (STitle) 5310**] in [**3-16**] weeks
Completed by:[**2136-8-16**]
|
[
"411.1",
"414.01",
"518.0",
"V45.82",
"493.90",
"785.0",
"401.9",
"998.11",
"530.81",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"99.04",
"88.72",
"99.07",
"99.05",
"36.13",
"34.03"
] |
icd9pcs
|
[
[
[]
]
] |
7156, 7194
|
4282, 5665
|
330, 433
|
7508, 7514
|
2215, 4259
|
7663, 7806
|
1722, 1983
|
5886, 7133
|
7215, 7487
|
5691, 5863
|
7538, 7640
|
1998, 2196
|
280, 292
|
461, 1209
|
1231, 1461
|
1477, 1706
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,347
| 199,560
|
37820
|
Discharge summary
|
report
|
Admission Date: [**2145-9-22**] Discharge Date: [**2145-9-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Syncope, Bradycardia, asystole
Major Surgical or Invasive Procedure:
Pacemaker placement [**2145-9-22**]
History of Present Illness:
86 y/o male with pmh significant for mild aortic stenosis, CAD
s/p four vessesl CABG in [**2137**], presyncopal episodes, being
transferred from medicine to CCU after being found unresponsive
in his room. He regained consciousness without intervention.
Telemetry at the time showed asystole with a 15 second pause,
and junctional escape rhythm. He denied any chest pain or
shortness of breath around this event.
.
He was initially admitted to medicine today for workup of
syncope. he reports having a 1.5 year history of presyncopal
episodes, consisting of facial flushing, diaphoresis, and light
headedness. he reports having to sit down during these episodes
otherwise he feels he would pass out, however he has actually
never syncopized. He has undergone two holter monitoring
episodes in [**2142**] and [**2143**] without any significant findings. He
is quite active, swimming twice weekly, playing tennis once
weekly and walking up several flights of stairs at work, but he
has never had these episodes during exertion. In addition, he
has never had shortness of breath or chest pain with physical
exertion either. He reports yesterday he had two presyncopal
episodes while seated. Today, he was driving on storrow drive
this morning when he hit a lamp post on the side of the road.
He remembers waking up in his car and stepping outside. A
driver behind the patient, stopped, and told the patient he had
witnessed him veer over to the left and then veer over to the
right, hitting the lamp-post. The patient only remembers waking
up after hitting the lamp-post. He was uninjured during this
accident.
.
The patient reports he took his normally prescribed dose of
metoprolol 25mg this morning. he does not take any other nodal
blocking agents.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
In the ED, initial vitals were 98.0, 60, Bp142/53, 21 95% RA.
He was admitted to the floor for syncope workup.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: [**2137**] at [**Hospital1 336**] LIMA to LAD, vein to diag, vein to OM, vein
to PLV.
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
BPH s/p prostatectomy in [**2106**]
bilateral inguinal hernia repairs
overactive bladder
hyperlipidemia
Social History:
-Tobacco history: none
-ETOH: 1 beverage every other day
-Illicit drugs: none
Family History:
Father with lung cancer.
Mother died of accident.
Physical Exam:
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVP.
CARDIAC: normal S1, S2. 3/6 systolic murmur with radiation to
carotids.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
CXR ([**9-22**])-
Left-sided pleural effusion versus pleural thickening as
described above.
Linear atelectatic changes within the left lower lobe. No
displaced rib fracture seen. However, if clinical concern for
rib fracture persists, recommend dedicated rib series.
.
[**2145-9-22**] 10:50AM BLOOD WBC-10.5 RBC-4.75 Hgb-13.9* Hct-41.9
MCV-88 MCH-29.3 MCHC-33.2 RDW-13.8 Plt Ct-216
[**2145-9-23**] 06:50AM BLOOD WBC-10.9 RBC-4.41* Hgb-13.0* Hct-39.8*
MCV-90 MCH-29.5 MCHC-32.7 RDW-14.4 Plt Ct-216
[**2145-9-22**] 10:50AM BLOOD Neuts-77.7* Lymphs-16.6* Monos-4.9
Eos-0.5 Baso-0.2
[**2145-9-22**] 06:09PM BLOOD PT-12.8 PTT-27.6 INR(PT)-1.1
[**2145-9-23**] 06:50AM BLOOD Plt Ct-216
[**2145-9-22**] 10:50AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-143
K-4.1 Cl-107 HCO3-27 AnGap-13
[**2145-9-23**] 06:50AM BLOOD Glucose-93 UreaN-22* Creat-1.2 Na-141
K-4.1 Cl-108 HCO3-26 AnGap-11
[**2145-9-22**] 10:50AM BLOOD CK(CPK)-70
[**2145-9-22**] 10:50AM BLOOD cTropnT-<0.01
[**2145-9-23**] 06:50AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1
Brief Hospital Course:
86 y/o male with CAD s/p 4 vessel CABG, presyncopal episodes,
presenting with syncope and long pauses on telemetry.
.
# Syncope/ICD placement: In the ED, he was noted to be
bradycardic to the 40s. He was admitted to the medicine floor.
Shortly after arrival on the floor, he syncopized, and a code
blue was called. Telemetry showed slowing of the sinus rate with
an eventual 17.5 s pause with 1 junctional escape only. He
resumed SR again without intervention. He was admitted to the
CCU. Here he again had 2 sinus pauses of ~4-5s each with
associated presyncope. Telemetery with sinus bradycardia and
asystole. Patient experienced one of his presyncopal episodes
during 5 second pause and an unresponsive episode with asystole.
Though he has history of CAD, no evidence of ACS. Potentially
sick sinus syndrome. Pacemaker was placed by Dr. [**Last Name (STitle) **] on
[**2145-9-22**]. Overnight, patient required pacing for only a few
beats, mostly using native conduction. Patient was restarted on
his beta blocker. Pain control was well controlled with tylenol.
Patient to continue cephalexin 500mg every 6 hours to complete a
total of a 3 day course.
.
# Coronary Artery Disease: s/p 4 vessel CABG in [**2137**].
Continued on aspirin 81 mg PO daily.
.
#Urinary Frequency: continued on oxybutynin.
.
# Hyperlipidemia: continued on simvastatin 30mg PO daily
Medications on Admission:
aspirin 81mg
metoprolol 25mg PO BID
simvastatin 30mg PO daily
Centrum silver with selenium, folate, vitamin C
Vitamin B12
Vitamin D
Co-enzyme Q
Citracal
oxybutynin
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Centrum Silver Tablet Sig: One (1) Tablet PO daily ().
4. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for PM implant for 9 doses.
Disp:*9 Capsule(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
8. Coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO daily ().
9. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Bradycardia
.
Secondary diagnoses:
-dyslipidemia
-s/p CABG [**2137**]
Discharge Condition:
Afebrile, vital signs stable, ambulatory.
Discharge Instructions:
You were admitted to the hospital for a syncopal episode. While
here you had a low heart rate and was therefore transferred to
the ICU for closer monitoring. It was determined by the
cardiology team that you needed a pacemaker placed. This was
performed on [**9-22**]. Your rhythms and rates were watched and were
all within normal limits. Your pacemaker site was examined and
showed no signs of active bleed or infection.
.
The following medication changes were made:
1. You will continue cephalexin 500mg every 6 hours to complete
a total of a 3 day course.
.
Please keep all of your follow-up appointments listed below.
.
If you experience any chest pain/pressure, severe shortness of
breath, uncontrolled fevers, loss of consciousness, change in
mental status or any other concerning medical symptoms, please
contact your PCP or go to the emergency department.
Followup Instructions:
Please keep all of your follow-up appointments listed below:
.
1. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2145-9-29**] 3:00
Completed by:[**2145-9-23**]
|
[
"427.81",
"424.1",
"788.41",
"V45.81",
"427.5",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
7304, 7310
|
4953, 6317
|
292, 330
|
7423, 7467
|
3910, 4930
|
8385, 8590
|
3275, 3326
|
6531, 7281
|
7331, 7345
|
6343, 6508
|
7491, 8362
|
3341, 3891
|
7366, 7402
|
2871, 3025
|
222, 254
|
358, 2763
|
3056, 3161
|
2785, 2851
|
3177, 3259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,787
| 151,822
|
7601
|
Discharge summary
|
report
|
Admission Date: [**2185-3-3**] Discharge Date: [**2185-3-5**]
Date of Birth: [**2142-9-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
palitations/PA Fib
Major Surgical or Invasive Procedure:
MI MAZE/LAA resection [**2185-3-3**]
History of Present Illness:
42 yo male with PA Fib for approx. 4 years. When he is in A fib,
he gets severe palpitations associated with dyspnea and angina.
Experiences PAFib about 5 times per week and has undergone
6cardioversions in the past year. Has been off coumadin for
several years. Referred for surgical intervention.
Past Medical History:
PAFib ( s/p DCCV x6)
cervical spine injury s/p rod [**2176**]
low back pain
? CVA- no symptoms- findings on CT scan/MRI at time of spine
surgery
renal calculi
other PSH: knee arthroscopy, hernia repair, cerv. spine [**Doctor First Name **].
Social History:
works in auto body
active smoker [**1-26**] ppd x 30 years
occasional ETOH
lives with wife and 3 kids
Family History:
brother with open heart surgery at age 50
mother with CAD at 61
Physical Exam:
HR 84 RR 14
NAD
skin- cardioversion burns noted
neck supple, full ROM
CTAB
RRR no murmur noted
extrems warm,well-perfused, no edema or varicosities noted
grossly intact neurologically
2+ bil. fem/DP/PT/radials
no carotid bruits appreciated
Pertinent Results:
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2185-3-5**] 7:37 AM
CHEST (PORTABLE AP)
Reason: interval evaluation of pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
42 year old man ws/p Mini maze with chest tube removal with
bilateral pneumothorax
REASON FOR THIS EXAMINATION:
interval evaluation of pneumothorax
REASON FOR EXAMINATION: Followup of a patient after Mini-Maze
procedure and chest tube removal.
Portable AP chest radiograph compared to [**2185-3-4**].
The right internal jugular line tip is in distal SVC, unchanged
in position. There is stable appearance of the cardiomediastinal
silhouette. Interval increase in right lower lung predominantly
retrocardiac but also more lateral opacity is consistent with
atelectasis accompanied by right pleural effusion. The rest of
the lungs are unremarkable. The right pneumothorax is not
demonstrated on the current film. Tiny left apical pneumothorax
is still present. There is interval decrease in small amount of
subcutaneous left lower neck emphysema.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2185-3-7**] 9:22 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 27740**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 27741**] (Complete)
Done [**2185-3-3**] at 12:50:26 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**]
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2142-9-5**]
Age (years): 42 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: LAA ligation/MAZE
ICD-9 Codes: 427.31, 424.0
Test Information
Date/Time: [**2185-3-3**] at 12:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: [**Pager number **]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-procedure: No spontaneous echo contrast is seen in the left
atrial appendage. Right ventricular chamber size and free wall
motion are normal. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque.. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
No mitral regurgitation is seen. There is no pericardial
effusion.
Post Procedure: 3-d and 2-d images confirm complete ligation of
LAA. Other parameters as pre-procedure.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2185-3-3**] 12:54
?????? [**2180**]
[**2185-3-5**] 05:48AM BLOOD WBC-9.8 RBC-4.34* Hgb-12.7* Hct-37.8*
MCV-87 MCH-29.3 MCHC-33.7 RDW-12.4 Plt Ct-257
[**2185-3-5**] 05:48AM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.1
[**2185-3-5**] 05:48AM BLOOD Plt Ct-257
[**2185-3-5**] 05:48AM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-141
K-4.2 Cl-102 HCO3-31 AnGap-12
[**2185-3-2**] 11:25AM BLOOD ALT-19 AST-26 LD(LDH)-158 AlkPhos-86
Amylase-93 TotBili-0.4
[**2185-3-5**] 05:48AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.8
Brief Hospital Course:
Admitted [**3-3**] and underwent minimally invasive Maze procedure
with pulm. vein isolation/LAA resection. Transferred to CVICU in
stable condition on a propofol drip.Started coumadin per
protocol and indomethacin. Extubated the following AM and
transferred to the floor later that afternoon. Chest tubes
removed and gently diuresed. Indomethacin, colchicine,coumadin
and protonix started per protocol. Cleared for discharge to home
with services on POD #2. Pt.is to make an appt. with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] (neurology) in 2 weeks.
Medications on Admission:
dofetilide 250 mcg [**Hospital1 **]
ASA 81 mg daily
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 7 days.
Disp:*7 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
5. Indomethacin 75 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day for
2 days: Take as directed by Dr. [**Last Name (STitle) **] for INR of [**2-26**].5.
Disp:*40 Tablet(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Motrin 600 mg Tablet Sig: One (1) Tablet PO four times a
day: take with food.
Disp:*120 Tablet(s)* Refills:*2*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation
prior cerv. spine injury (s/p rod)
low back pain
?CVA noted on prior CT scan/MRI
Discharge Condition:
Good.
Discharge Instructions:
Follow medcations on discharge instructions.
Do not drive while taking pain medication.
Do not lift more than 10 lbs for 1 month.
Shower tomorrow after taking dressings off.
Call our office for temp>101.5
No lotions, creams or powders on any incision.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) 914**] for 4 weeks.
Make an appt. with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ( neurology) in 2 weeks.
[**Telephone/Fax (1) 657**]
Completed by:[**2185-3-7**]
|
[
"724.2",
"427.31",
"V12.59",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8381, 8387
|
6244, 6815
|
303, 342
|
8532, 8540
|
1413, 1549
|
8840, 9142
|
1071, 1136
|
6917, 8358
|
1586, 1669
|
8408, 8511
|
6841, 6894
|
8564, 8817
|
4815, 6221
|
1151, 1394
|
245, 265
|
1698, 4766
|
370, 670
|
692, 936
|
952, 1055
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,011
| 199,131
|
43314
|
Discharge summary
|
report
|
Admission Date: [**2186-6-27**] Discharge Date: [**2186-7-4**]
Date of Birth: [**2115-11-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional angina
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 2(reverse saphenous vein graft to the
posterior descending artery and the first marginal branch)
[**2186-6-28**]
History of Present Illness:
This is a 70 yo male with multiple
cardiac risk factors who presented to Dr. [**Last Name (STitle) 6512**] with
exertional
angina. In [**2185-11-4**], stress testing was abnormal. Subsequent
cardiac catheterization in [**2185-12-5**] revealed multivessel
coronary disease. He is now referred for surgical
revascularization.
Past Medical History:
Coronary Artery Disease
PMH:
- Hypertension
- Dyslipidemia
- Diabetes Mellitus, Diabetic Retinopathy
- Chronic Renal Insufficiency, baseline Cr 2.0 - 2.2
- Benign Prostatic Hypertrophy
- Cerebral Aneurysm(4mm middle cerebreal artery aneurysm)
- Hiatal Hernia with occasional GERD
- Obstructive Sleep Apnea, refuses CPAP
- Erectile Dysfunction
- Anemia
- Hemorrhoids
- Arthritis in knees
- Colonic Adenoma
Social History:
Lives with: Wife
Occupation: Building inspector
Tobacco: 60 PYH, quit [**2153**]
ETOH: Denies
Family History:
Denies premature coronary disease
Physical Exam:
VSS: 97'3T, 172/68, 48, 100%RA
General: A&Ox3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: trace
Varicosities: R GSV slightly enlarged, L GSV appears OK
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2 - bilateral femoral bruits noted
on prior exams-not auscultated today. (R)Fem cath site->C/D/I.
No
induration/hematoma appreciated.
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid pulses= 2+(B)
Pertinent Results:
[**2186-6-28**] Intra-op TEE
Conclusions
Prebypass
The left atrium is dilated. No spontaneous echo contrast is seen
in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium. A patent foramen ovale is present with a left-to-right
shunt across the interatrial septum seen at rest. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The descending thoracic aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
Postbypass
The patient is A paced and on no inotropes. Biventricular
systolic function is unchanged. Mitral and tricuspid
regurgitation remain trace. The thoracic aorta is intact post
decannulation.
CXR:
[**2186-7-1**]:
No change in the size of marked cardiomegaly and as previously
stated, a
pericardial effusion is suspected and could be further evaluated
with
echocardiography. Probable mild interstitial edema.
[**2186-6-30**]: No evidence of pneumonia. Improving bilateral lower
lobe atelectasis. Enlarging cardiac size suggests an enlarging
pericardial effusion which could be evaluated with
echocardiography.
[**2186-7-1**]:WBC-19.6* RBC-3.10* Hgb-10.0* Hct-29.2 Plt Ct-196
[**2186-6-27**] WBC-8.6 RBC-4.02* Hgb-12.8* Hct-37.3 Plt Ct-239
[**2186-7-1**] UreaN-49* Creat-2.4* Na-135 K-4.6 Cl-100
[**2186-6-29**] Glucose-154* UreaN-32* Creat-2.0* Na-139 K-4.8 Cl-106
HCO3-24
[**2186-6-28**] UreaN-27* Creat-1.5* Na-143 K-4.2 Cl-109* HCO3-25
[**2186-6-28**] UreaN-35* Creat-1.7*
[**2186-6-27**] Glucose-240* UreaN-43* Creat-1.9* Na-141 K-4.9 Cl-106
HCO3-26
[**2186-7-1**] Mg-2.8* [**2186-6-30**] Mg-2.5
Brief Hospital Course:
Mr.[**Known lastname 93291**] was brought to the Operating Room on [**2186-6-28**]
where he underwent Coronary Artery Bypass x2 (reverse saphenous
vein graft to the posterior descending artery and the first
marginal branch)with Dr.[**Last Name (STitle) **]. Please refer to operative
report for further surgical details. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. POD 1 the patient awoke neurologically
intact and was extubated without difficulty. He weaned from
inotropic and vasopressor support. Beta blocker/Statin/Aspirin
and diuresis was initiated. He was hypertensive initially,
controlled with IV NTG and converted to his home PO
anti-hypertensive medication. He transferred to the telemetry
floor for further recovery. Chest tubes and pacing wires were
discontinued without complication per protocol. His baseline
Creatnine of 1.7 peaked to 2.4 with good urine output. On
[**2186-7-1**] he had increased shortness of breath, and appeared to
have volume overload with a widened cardiac silhouette on CXR.
An echocardiogram was done and revealed a small pericardial
effusion. He was gently diuresed toward his preoperative weight.
Electrolytes were repleted as needed. His pain was well
controlled with oral pain medications. He was evaluated by the
physical therapy service for evaluation and assistance with
strength and mobility. By the time of his discharge his
creatnine had come back down to 2. He was cleared for discharge
on POD#6 to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] rehab. All follow up appointments were
advised..
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 2 (Two) Tablet(s) by mouth once a
day
ATENOLOL - 50 mg Tablet - 1 (One) Tablet(s) by mouth once a day
ENALAPRIL MALEATE - 20 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
FUROSEMIDE - 20 mg Tablet - 2 (Two) Tablet(s) by mouth once a
day
HUMALOG PEN - 100 unit/mL Insulin Pen - 12unit breakfast,
12units
lunch, and 15 units dinner
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 64 units once a day/HS
ISOSORBIDE MONONITRATE - 30 mg Tablet Extended Release 24 hr - 1
(One) Tablet(s) by mouth once a day
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - [**2-6**]
Tablet(s) sublingually as needed for chest pain
SIMVASTATIN - 80 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
TERAZOSIN - 1 mg Capsule - 1 (One) Capsule(s) by mouth once a
day/HS
Medications - OTC
ACETAMINOPHEN [ARTHRITIS PAIN RELIEVER] - (OTC) - 650 mg Tablet
Extended Release - 2 (Two) Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - (OTC) - 400 unit Tablet,
Chewable
- 1 (One) Tablet(s) by mouth once a day
DIPHENHYDRAMINE-ACETAMINOPHEN [ACETAMINOPHEN PM] - (Prescribed
by Other Provider) - 500 mg-25 mg Tablet - 1 (One) Tablet(s) by
mouth once a day/HS
LORATADINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime
PRN
Discharge Medications:
1. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
2. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. insulin glargine 100 unit/mL Cartridge Sig: 75 units
Subcutaneous with dinner.
10. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ACHS: per RISS.
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day) as
needed for wheezing.
13. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Coronary Artery Disease
PMH:
- Hypertension
- Dyslipidemia
- Diabetes Mellitus, Diabetic Retinopathy
- Chronic Renal Insufficiency, baseline Cr 2.0 - 2.2
- Benign Prostatic Hypertrophy
- Cerebral Aneurysm(4mm middle cerebreal artery aneurysm)
- Hiatal Hernia with occasional GERD
- Obstructive Sleep Apnea, refuses CPAP
- Erectile Dysfunction
- Anemia
- Hemorrhoids
- Arthritis in knees
- Colonic Adenoma
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], [**2186-7-30**], 1:15 in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **] [**Location (un) 551**] [**Hospital Unit Name **]
Cardiologist Dr[**Doctor Last Name 93292**] office will contact you to schedule an
appointment
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 38274**],[**First Name3 (LF) **] X. [**Telephone/Fax (1) 3530**] in [**5-9**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2186-7-4**]
|
[
"250.50",
"V43.65",
"414.01",
"413.9",
"403.90",
"327.23",
"362.01",
"600.00",
"427.31",
"272.4",
"276.69",
"585.9",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8429, 8551
|
4193, 5881
|
329, 469
|
9000, 9156
|
2155, 4170
|
9944, 10659
|
1380, 1416
|
7204, 8406
|
8572, 8979
|
5907, 7181
|
9180, 9921
|
1431, 2136
|
271, 291
|
497, 823
|
845, 1252
|
1268, 1364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,454
| 110,944
|
9406
|
Discharge summary
|
report
|
Admission Date: [**2184-12-16**] Discharge Date: [**2184-12-21**]
Date of Birth: [**2104-11-3**] Sex: M
Service: MEDICINE
Allergies:
Biaxin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
hypotension, altered mental status
Major Surgical or Invasive Procedure:
Left internal jugular central line
History of Present Illness:
80 yo M tobacco smoker with severe COPD on continuous home
oxygen 2L NC (FEV1/FVC: 60%, FEV1: 17% and FVC: 28% in '[**82**]) and
lung CA on day 16 of cycle 2 of Navelbine, who was recently
admitted to [**Hospital1 18**] for CCOPD exacerbation and cellulitis/DVT
([**Date range (1) 32120**]). After his last admission, he was started on a
prednisone taper and continues to be on prednisone 15mg once
daily. He lives in an [**Hospital3 **] facility in [**Location (un) **] and
has been receiving chemotherapy as an out patient. This AM, the
pt was found covered in stool at the [**Hospital3 **] facility.
He was found by the staff to be weak and disoriented in addition
to incontinent of stool. As per the report sheet, he was
reported feeling "pretty good" with baseline sob/doe. However he
was found to be speaking in [**1-30**] word sentences and EMT found the
pt to be hypotensive with BP of 84/54. The pt reports he
normally is able to walk [**4-2**] steps prior to developing SOB even
with oxygen however in recent days he does not believe he can do
even that. He reports a possible fever several days previously
(measured by VNA but he was not how high), but without chills or
rigors. He denies any dysuria, urinary frequency, diarrhea, or
abdominal pain or n/v, head ache, neck stiffness or change in
vision including peripheral vision. The pt also denies any
significant back pain. He received tylenol for the fever and it
has since resolved. He denies any chest pain, palpitations, LE
edema. He denies any change in his appetite but reports he has
been eating a lot of sugar, he also denies any change in his
body weight or abdominal distension. He received a flu shot this
year and a pneumovax several years previously. The pt believes
he is here for his weekly chemotherapy tx and is unclear why he
was in the [**Name (NI) **] or the [**Hospital Unit Name 153**].
In the ED, the pt was found to be hypotensive to the 84/54 with
HR of 76 with oxygen saturation of 90% on RA. The pt was placed
on 4L NC with saturation in the mid 90s, however he was
desaturating to the 80s with movement. He was therefore started
on NRB in the ED. ABG at the time was the follow: 7.38/38/74. In
addition, he was found to have a WBC of 0.7, an ANC of < 500,
and lactate 2.1. The pt also had a proBNP of 1712. UA was
negative. CXR demonstrated a right para mediastinal mass which
measured 4.7 x 3.9 cm in size (unchanged from previous) and
vague nodular densities at lung bases with some pulmonary edema
but no focal infiltrates. A right IJ was placed. CVP was
initially measured between [**9-8**], and after fluid resuscitation
was found to be 20. He was given cefepime and vancomycin for
presumed febrile neutropenia as well as dexamethasone 10mg IV x1
as he is chronically on prednisone. In addition, the pt received
2unit of PRBC for Hct of 23.7 and 3L of NS and was transferred
to the [**Hospital Unit Name 153**].
Past Medical History:
Oncology History: Mr. [**Known lastname 21781**] was initially found to have
multiple polyps on routine colonoscopy in [**2182-11-28**]. A repeat
colonoscopy on [**2183-9-2**] with bx showed high grade dysplasia and
CIS. Follow up PET scan demonstrated abnormal FDG activity in a
lung nodule and in the transverse colon. On [**2184-7-2**] a
biopsy of the right upper lobe nodule yielded an
undifferentiated carcinoma which was positive for CK 7, negative
for CK 20 and TTF-1 and LCA. Although this pattern is not
specific it is compatible with primary pulmonary carcinoma.
After much discussion, a medical regimen consisting of Nevelbine
wsa initiated as his significant COPD and other co-morbidities
precluded a surgical approach. He is now on cycle two of
Nevelbine which he has tolerated well as an outpt.
PAST MEDICAL HISTORY:
1. Presumed primary lung CA metastatic to colon on Navelbine
2. COPD on 2L home oxygen. PFT on [**2183-9-18**] with FEV1/FVC: 60%,
FEV1: 17% and FVC: 28%.
3. CAD: ETT-MIBI [**1-27**] w/ moderate partially reversible inferior
defect, no c/o angina, med management -echo ([**9-30**]): EF 60%, no
WMA, could not assess PASP
4. Hyperlipidemia
5. Type II Diabetes
6. Chronic Renal Insufficiency baseline between 1 to 1.3.
7. Hypoxemia
8. History of DVT. Treated with heparin and coumadin.
9. Pelvic fracture and liver laceration from a MVA.
10. Anemia
11. Depression
12. Alcoholism
Social History:
He is now living in an [**Hospital3 **] facility. He requires
continuous oxygen. He is a former construction worker who never
married and has no children. He is estranged from his two
sisters.
[**Name (NI) **]: 1 PPD x 60 years, quit smoking 1 mo ago.
EtOH: Used to drink alcohol heavily, but quit 1 year ago
Illicit drugs: He denies IVDU.
Family History:
Father: deceased at 85. He had a history of DM.
Mother: deceased at 85 from "natural causes."
Brother: deceased from an accident at the age of 19.
Sister: His sisters are alive, but he doesn't communicate with
them.
Physical Exam:
VS in ED: T: 97.3, HR: 52 (as high as 72), BP: 91/38 (as low as
76/42), RR: 16, SaO2: 90% on RA
VS in [**Hospital Unit Name 153**]: T: 97.6, HR: 74, BP: 106/47, RR: 16, SaO2: 98% on
NRB
GEN: elderly male who appears his stated age, wearing FM.
conversing in short [**3-2**] word sentences.
HEENT: surgical pupils, EOMI, anicteric, op clear, mmm
CHEST: [**Month (only) **]. air movement with prolonged expiratory phase. no
crackles or obvious wheezing.
Neck: Right IJ
CV: rrr, s1, s2, no m/r/g
ABD: well healed vertical surgical wound in midline, markedly
distended, soft, NT, BS+ bilaterally, tympanic to percussion, no
obvious fluid wave
EXT: wwp, +1 non-pitting edema, mild chronic venous stasis
changes
NEURO: A+O x3 ([**Hospital1 18**], [**Location (un) **], [**Last Name (un) 2450**], [**Last Name (un) 24934**], himself, his
[**Last Name (un) **])
no rectal tone examined given ANC <500.
Pertinent Results:
[**2184-12-16**] 11:21PM O2 SAT-77
[**2184-12-16**] 10:40PM LD(LDH)-233 CK(CPK)-600*
[**2184-12-16**] 10:40PM CK-MB-3 cTropnT-<0.01
[**2184-12-16**] 10:40PM CORTISOL-13.5
[**2184-12-16**] 07:43PM LACTATE-1.7
[**2184-12-16**] 07:43PM HGB-10.5* calcHCT-32 O2 SAT-59
[**2184-12-16**] 06:15PM TYPE-ART PO2-74* PCO2-48* PH-7.38 TOTAL
CO2-29 BASE XS-1
[**2184-12-16**] 04:49PM URINE HOURS-RANDOM
[**2184-12-16**] 04:49PM URINE UHOLD-HOLD
[**2184-12-16**] 04:49PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2184-12-16**] 04:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2184-12-16**] 12:47PM GLUCOSE-275* LACTATE-2.1*
[**2184-12-16**] 12:30PM GLUCOSE-260* UREA N-24* CREAT-1.4* SODIUM-136
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15
[**2184-12-16**] 12:30PM ALT(SGPT)-15 AST(SGOT)-32 CK(CPK)-935* ALK
PHOS-76 AMYLASE-34 TOT BILI-0.4
[**2184-12-16**] 12:30PM cTropnT-<0.01
[**2184-12-16**] 12:30PM CK-MB-3 proBNP-1712*
[**2184-12-16**] 12:30PM TOT PROT-6.1* CALCIUM-8.3* PHOSPHATE-4.0#
MAGNESIUM-1.7
[**2184-12-16**] 12:30PM WBC-0.7*# RBC-3.21* HGB-8.1* HCT-23.7*
MCV-74* MCH-25.3* MCHC-34.3 RDW-20.2*
[**2184-12-16**] 12:30PM NEUTS-32* BANDS-12* LYMPHS-28 MONOS-20* EOS-0
BASOS-0 ATYPS-0 METAS-8* MYELOS-0
[**2184-12-16**] 12:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2184-12-16**] 12:30PM PLT SMR-UNABLE TO PLT COUNT-390
[**2184-12-16**] 12:30PM PT-17.9* PTT-35.4* INR(PT)-2.2
Micro:
[**2184-12-16**] 1:00 pm BLOOD CULTURE VENIPUNCTURE.
AEROBIC BOTTLE (Preliminary):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) 26976**] [**Last Name (NamePattern1) 32121**], RN @ 4I [**Numeric Identifier 6026**] @ 0353AM
ON
[**2184-12-17**].
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC BOTTLE (Pending):
CXR [**2184-12-16**]:
The right paramediastinal mass is not significantly changed in
size, and on this radiograph measures 4.7 x 3.9 cm in size.
Vague nodular densities are again seen at the right lung base
superimposed over the pericardial fat pad, and also at the left
lung base along the diaphragmatic border. There are slightly
increased interstitial markings asymmetrically involving the
right hemithorax relative to the left. The cardiac and
mediastinal silhouettes appear unchanged. Aortic contour appears
within normal limits. No definite pleural effusions, although
extreme right costophrenic angle has been coned off of this
image. No evidence of pneumothorax. Focal pleural thickening/rib
fractures again seen at the lateral mid thoracic ribs on the
right.
IMPRESSION: Slight and asymmetric interstitial prominence of the
right hemithorax likely edema."
ECG [**2184-12-16**]: poor baseline ? for aflutter, LAD, RSR' in V1-V4,
no ST changes, poor R wave progression
Brief Hospital Course:
A/P: This is an 80 year old gentleman with lung cancer
metastatic to colon undergoing Navelbine chemotherapy, severe
COPD on home oxygen undergoing taper who was admitted with
sepsis to [**Hospital Unit Name 153**] and found to be neutropenic with Klebsiella
bacteremia. In [**Name (NI) 153**], pt had transient pressor requirement along
with IVF support for hypotension which resolved by HD 2. Stress
dose steroids were started. He was generally afebrile through
course in [**Hospital Unit Name 153**] and did not require intubation By the end of the
[**Hospital Unit Name 153**] stay once he was breathing with adequate saturation on 2L.
He was continued on empiric vancomycin, cefepime, and received
one dose of gentamicin. Blood cultures from admission grew 2 out
4 bottles with final culture being Klebsiella sensitive to
cefepime, resistant to levofloxacin and gentamcin. Vancomycin
was discontinued, cefepime was maintained Per Dr. [**Name (NI) 3274**], pt
received GM-CSF for his neutropenia. [**Hospital Unit Name 153**] course also remarkable
for intermittent atrial flutter seen on telemetry and
supratherapeutic INR for which coumadin was held. LE dopplers
revealed no presence of DVT.
.
On transfer to the general medical [**Hospital1 **] ([**2183-12-19**]), the patient
was afebrile, hemodynamically stable with no pressor or IVF
requirement. His neutropenia was noted to resolve s/p GM-CSF
treatment. Surveillance blood cultures taken on the His
respiratory status was still not at baseline and therefore the
pt was steroid regimen was made more potent by changing the
steroid to solumedrol. This was noted to improve the patients
respiratory status. The pt also was noted to become
significantly dysthymic, becoming tearful at times and with
evidence of hallucinatory behavior and therefore a psychiatry
consult was called. It was noted that the patients
antidepressants had not been given during his [**Hospital Unit Name 153**] stay and
these were therefore restarted with subsequent improvement in
his mental status. He was able to sleep, appeared euthymic and
no longer exhibited hallucinatory behavior.
By discharge the patient had returned to his baseline
respiratory status and had no signs of infection including
fever, chills, malaise or gastrointestinal symptoms. Given his
ongoing need to complete his IV antibiotic course, severe COPD,
metastatic lung cancer, ongoing chemotherapy and his home
situation (he lives alone), it was believed, with agreement from
the physical therapy service, that he would benefit from
transfer to an extended care facility.
In summary, this is an 80 year old gentleman with metastatic
lung cancer on chemotherapy, severe COPD, type II diabetes, DVT,
and depression who was admitted to [**Hospital Unit Name 153**] for sepsis, COPD
exacerbation, and found to have Klebsiella bacteremia. He was
treated with IV cefepime for his infection and high dose
steroids for his COPD. Sepsis was likely related to
immunosuppression secondary to chemotherapy. He is to continue
5 more days of antibiotics for his infection and a prednisone
taper for his COPD exacerbation. He will follow up with Dr.
[**Last Name (STitle) **] for further coordination of his chemotherapy for his
metastatic lung cancer.
Issues and plan from this hospitalization.
.
1. Sepsis/hypotension: Secondary to Klebsiella
infection/bacteremia. Source not yet clear although pt had R
PICC which is possible nidus; however culture from tip negative.
Certainly he was more susceptible to infection given his
chemotherapy-related neutropenia (he was 2 weeks out from last
treatment, hence he was at the nadir) His hemodynamic status
appears to have returned to nl.
-- continue IV cefepime for 5 days
--surveillance blood from [**12-17**] and [**12-18**] are negative thus far.
2. COPD: appears back at baseline, exacerbation likely secondary
to infection.
-Cont. oxygen supplementation, he is back at baseline O2
requirement
-albuterol nebs and tiatropium (replaces ipratropium) atrovent
nebs only as needed, --continue prednisone taper (see discharge
plan).
3. Neutropenia, resolved s/p GM-CSF treatment
-appears to be improving, continue to monitor CBC and ANC.
4. Metastatic lung cancer, on Navelbine treatment, will have to
defer further cycles for now, will coordinate with Dr. [**Last Name (STitle) **]
to determine timing of further treatment.
5. History of DVT: on coumadin was held for supratherapeutic
INR.
-LENI this admission negative for DVT. DVT from [**10-2**] now gone.
-Transitioning to Lovenox, needs INR to be back in [**12-31**] range
before restarting this.
-Would check INR every 2 days the first few days after
discharge.
-when INR in therapeutic range start 150 mg SC lovenox once a
day
6. Atrial flutter/atypical rhythm:
-Asymptomatic
7. Type II Diabetes: continue insulin with [**Hospital1 **] NPH with SS.
Although this may be difficult to control with addition of
higher dose of steroids, will attempt control with sub Q
insulin.
8. Abdominal distention: this appears to be normal for this pt.
Had this on admission too. Appears that he had this as far back
as [**2184-5-28**] and plain films at that time were negative for
any abnormality including SBO, free air or ascites.
-if worsens would consider repeat imaging.
9. Chronic Renal Insufficiency: Cr appears back at baseline
10. Depression: Have changed psychatric regimen, had some signs
of depression and and hallucinations this admission, resolved
when we restarted pt on trazodone and venlafaxine.
-Continue trazodone 150 mg qHS, and Effexor 75 mg qAM
11. Anemia: Known chronic anemia, had acute [**Month (only) **]. in Hct as well.
Guaiac is currently unknown (given his ANC <500, no rectal exam
performed). S/p 2 units this admission.
-cont. epogen and iron supplements.
12. FEN: diabetic, heart friendly, diet.
.
13. Access: Mid-line venous catheter.
.
14. Communication: Sister: [**Name (NI) 17**] [**Name (NI) **] (HCP): [**Telephone/Fax (1) 32122**]
.
15. Disp: Extended care facility.
.
Code status remains full.
Medications on Admission:
1. Navelbine as outpt (inhibits microtubule formation).
2. Advair 250/50 1 puff [**Hospital1 **]
3. Combivent and albuterol nebs
4. Prednisone 15mg once daily
5. Glyburide 10mg [**Hospital1 **]
6. Insulin regular SS
7. Coumadin 5mg QHS
8. Effexor XR 75mg once daily
9. Trazodone 100mg QHS
10. Lipitor 20 mg QHS
11. Protonix 40mg once daily
12. Colace 100mg [**Hospital1 **]
13. Senna 1 tab once daily
14. Fe 325mg [**Hospital1 **]
Discharge Medications:
1. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 3 days: From [**2184-12-22**] to [**2184-12-24**].
Disp:*3 Tablet(s)* Refills:*0*
4. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous Q8H
(every 8 hours) for 5 days.
Disp:*15 piggyback (2 g per piggyback)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day: in morning.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
7. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed: Use only if neededed.
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation
Inhalation Q3-4H (Every 3 to 4 Hours) as needed.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain or fever.
12. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation.
Inhalation Q4H (every 4 hours).
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
injection Subcutaneous as directed: Use standard sliding scale,
fingersticks four times a day, 2 units for 151-200, 4 units for
201-250, 6 units 251-300, 8 units for 301-350, 10 units for
351-400. 12 for greater than 400 and [**Name8 (MD) 138**] M.D.
If less than 50 give juice, [**Name8 (MD) 138**] M.D.
18. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO at bedtime as needed for agitation.
19. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: from [**2184-12-25**] to [**2184-12-27**].
20. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: From [**2184-12-28**] to [**2184-12-30**].
21. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO once a day:
starting [**2184-12-31**].
22. Outpatient Lab Work
Please check chemistries, CBC, and coagulation studies on
[**2184-12-22**].
23. Lovenox 150 mg/mL Syringe Sig: One (1) injection
Subcutaneous once a day: Please do not start this medication
until INR has returned to therapeutic range.
24. Insulin NPH-Regular Human Rec 50-50 unit/mL Suspension Sig:
One (1) injection Subcutaneous twice a day: 10 units at
breakfast.
8 units at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Sepsis secondary to Klebsiella bacteremia
COPD exacerbation
Metastatic lung cancer
Atrial flutter
Depression
Discharge Condition:
Good. Breathing now returned to baseline. Afebrile, able to
work with physical therapy. Tolerating regular diet.
Discharge Instructions:
Please return to hospital if respiratory status starts to
deteriorate. (i.e)Gets more tachypneic or oxygen requirement
begins to increase).
Please return to hospital if lower extremity edema starts to
worsen.
Please continue prednisone taper and continue cefepime therapy
for 5 more days.
Please have pt follow up with Dr. [**Last Name (STitle) **] to coordinate
further treatment of metastatic lung cancer.
Followup Instructions:
Please have pt follow up with his oncologist Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at [**Hospital1 18**] ON [**2184-12-28**] at 10:30.
Please have patient follow up with his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 9556**].
Please have patient follow up with mental health therapist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26687**] of Mass Mental [**Telephone/Fax (1) 32123**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
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icd9cm
|
[
[
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] |
[
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icd9pcs
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[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,870
| 143,167
|
7200
|
Discharge summary
|
report
|
Admission Date: [**2204-2-29**] Discharge Date: [**2204-3-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization, cardioversion
History of Present Illness:
Dr. [**Known firstname 26693**] [**Known lastname **] is an 87yo retired male cardiothoracic
surgeon with h/o CAD with inoperable multivessel dz, 2 prior
anterolateral and inferior MI s/p BMS to pLAD in [**11/2195**], DES to
D1 in [**2-/2200**] c/b GIB in setting of anticoag, ICM with EF
30-40%, HTN, hyperlipidemia, colon and prostate CA, presenting
with increased anginal pain. The reports intermittent pain
throughout day of admission with relief of his symptoms with
nitro. He then developed crushing SSCP after taking a long walk
which did not respond to NTG. His pain is associated with
nausea, but denies dyspnea, cough, or diaphoresis. He denies
orthopnea and PND, but has had increased LE edema.
.
In the ED, Initial vitals 99.6, 90, 132/62, 16, 98% 2L. By the
time he arrived in the ED he was chest pain free. EKG showed
ST-E in III and aVF and ST-D in the lateral leads. His initial
TnT was 0.12. He was given ASA 325mg, Plavix 300mg, and started
on a heparin drip. His CXR showed possible opacity in left so he
was given IV levaquin 750mg x 1. He was guaiac. He was
transfered to [**Hospital1 1516**] for further management.
.
On the floor he was evaluated and taken to cath which showed
known proximal LCx and RCA occlusions, patent pLAD and D1 stents
with known occlusion of the LAD after D1, and filling via L-L
collaterals to the distal LAD and LCx. He developed CHF and new
Afib with RVR to the 120a post cath and was transfered to the
CCU for further management. His O2 requirement increased post
procedure and required diuresis with furosemide 20mg IV x 3 to
which he diuresed 3 litres. He continues to require 2 litres
supplemental oxygen. Regarding his new Afib with RVR, he
received 10mg IV metoprolol followed by 12.5mg PO metoprolol. He
was anticoagulated with heparin and started on warfarin and
underwent unsuccessful cardioversion. He was then loaded with
amiodarone and converted into sinus. Of note, the Pt reports
that he has had prior episodes of atrial fibrillation in [**2185**],
[**2190**], and [**2195**] which were asymptomatic except for a pulse in the
120s. At those times it resolved spontaneously. His Afib was
asymptomatic this admission as well, but given his CAD he was
unlikely to tolerate it for very long.
.
On transfer to the floor he is in sinus and stable on 2L O2. He
is CP free, able to lie flat, and feeling the best he has since
admission.
Past Medical History:
CARDIAC RISK FACTORS:: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: 2 prior anterolateral and
inferior MI s/p BMS to pLAD in [**11/2195**], DES to D1 in [**2-/2200**]
- Coronary artery disease: He has known multivessel disease
which is inoperable in [**2176**]. He underwent angioplasty and
stenting of a proximal LAD lesion in [**2195-11-1**] and then
had a repeat PCI of an LAD diagonal branch lesion in [**Month (only) 404**] of
[**2200**]. He is status post both anterolateral and inferior
infarctions, complicating an episode of profound GI bleeding,
respiratory insufficiency, and rapid atrial
fibrillation.
- Hyperlipidemia, on statin therapy.
- History of hypertension, on pharmacologic therapy.
- History of PAF, previously not on Coumadin [**3-5**] prior h/o GIB
- History of GI bleeding and chronic anemia
- Prostate cancer, status post XRT
- Radiation proctitis.
- Colon cancer status post sigmoidectomy in [**2175**].
- Pulmonary tuberculosis diagnosed in [**2143**].
Social History:
Denies alcohol, tobacco, and IVDU. Pt is a retired
cardiothoracic surgeon. He lives in [**Location (un) 26694**] in [**Location 1268**]
Family History:
No family history of early MI, otherwise non-contributory
Physical Exam:
VS: 98.6, 114/64, 84, 16, 93% on 2L
GENERAL: Pleasant elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Bibasilar crackles to [**2-4**] lungs, mod air movement. No
chest wall deformities, scoliosis or kyphosis. Resp were
unlabored, no accessory muscle use.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ pitting edema to knees bilaterally, LLE slightly
more than RLE. +2 tender hematomas on medial aspect of left knee
with ecchymoses and tracking down to ankles. No
edema/erythema/pain at left knee. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
admission labs-
[**2204-2-29**] 09:09PM BLOOD WBC-13.6*# RBC-3.28* Hgb-11.0* Hct-30.6*
MCV-93 MCH-33.5* MCHC-35.9* RDW-14.0 Plt Ct-174
[**2204-2-29**] 09:09PM BLOOD Neuts-94.9* Lymphs-2.2* Monos-2.6 Eos-0.1
Baso-0.2
[**2204-2-29**] 09:09PM BLOOD PT-13.7* PTT-29.1 INR(PT)-1.2*
[**2204-2-29**] 09:09PM BLOOD Glucose-150* UreaN-31* Creat-1.4* Na-145
K-3.9 Cl-111* HCO3-24 AnGap-14
[**2204-2-29**] 09:09PM BLOOD CK(CPK)-90
[**2204-2-29**] 09:09PM BLOOD cTropnT-0.12*
Reports
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
severe three vessel disease that was not significantly changed
from his
last cardiac catheterization. The LMCA had a 50% distal
stenosis. The
LAD was occluded in the mid-vessel but had widely patent stents
proximally and in the D1 branch. The LCx was occluded
proximally and
the OMs filled via left-left collaterals. The RCA was not
engaged as it
was known to be occluded.
2. Central aortic pressure was 134/69/97mmHg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Severe three vessel coronary artery disease.
2. Widely patent stents in the proximal LAD and D1 branch.
LE doppler
IMPRESSION: No evidence of deep vein thrombosis in the left leg.
[**2204-3-1**] C Cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
severe three vessel disease that was not significantly changed
from his
last cardiac catheterization. The LMCA had a 50% distal
stenosis. The
LAD was occluded in the mid-vessel but had widely patent stents
proximally and in the D1 branch. The LCx was occluded
proximally and
the OMs filled via left-left collaterals. The RCA was not
engaged as it
was known to be occluded.
2. Central aortic pressure was 134/69/97mmHg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Severe three vessel coronary artery disease.
2. Widely patent stents in the proximal LAD and D1 branch.
[**3-5**] Echo
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
near akinesis of the distal half of the septum and anterior
walls, and distal inferolateral walls. The apex is dyskinetic
and aneurysmal. The remaining walls contract well (LVEF 30-35%).
No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size and free wall motion are normal.
Complex (>4mm, non-mobile) plaque is seen in the abdominal aorta
(clip [**Clip Number (Radiology) **]). The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
Compared with the prior report (images unavailable for review)
of [**2200-4-25**], the findings are similar.
Brief Hospital Course:
On the floor he was evaluated and taken to cath which showed
known proximal LCx and RCA occlusions, patent pLAD and D1 stents
with known occlusion of the LAD after D1, and filling via L-L
collaterals to the distal LAD and LCx. He developed CHF and new
Afib with RVR to the 120a post cath and was transfered to the
CCU for further management. His O2 requirement increased post
procedure and required diuresis with furosemide 20mg IV x 3 to
which he diuresed 3 litres. He continues to require 2 litres
supplemental oxygen. Regarding his new Afib with RVR, he
received 10mg IV metoprolol followed by 12.5mg PO metoprolol. He
was anticoagulated with heparin and started on warfarin and
underwent unsuccessful cardioversion. He was then loaded with
amiodarone and converted into sinus as his amiodarone was
started. Of note, the Pt reports that he has had prior episodes
of atrial fibrillation in [**2185**], [**2190**], and [**2195**] which were
asymptomatic except for a pulse in the 120s. At those times it
resolved spontaneously. His Afib was asymptomatic this admission
as well, but given his CAD he was unlikely to tolerate it for
very long. After his amio gtt he was transitioned to 200mg TID
PO. He was also restarted on his imdur, he had been having
angina while off of the medication.
.
On transfer to the floor he is in sinus and stable on 2L O2. He
is CP free, able to lie flat, and feeling the best he has since
admission.
[**Hospital1 **] SERVICE BRIEF HOSPITAL COURSE:
Patient is a 87M with h/o CAD with inoperable multivessel dz, 2
prior MI s/p BMS to pLAD in [**11/2195**], DES to D1 in [**2-/2200**] c/b GI
bleed in setting of anticoag, ICM with EF 30-40%, HTN,
hyperlipidemia, h/o colon and prostate [**Hospital 4699**] transferred to CCU
for CHF and atrial fibrillation with RVR now s/p pharmacologic
cardioversion and diuresis who returned to Cardiology service
for further management. He was discharged on warfarin with a
goal INR of [**3-5**].5 for Afib given his history of GIB and
amiodarone for rhythm control.
.
#. CAD/Angina: Unintervenable disease. Patient had long history
of CAD and had 3VD. Patient's cardiac cath showed diffuse
disease. The plan is for medical management. Restarted Imdur
30mg PO daily with improvement of symptom control. Started
ranolazine 500mg PO BID for anginal control. Reduced ASA to 81mg
PO daily and discontinued clopidogrel given his is
anticoagulation with a heparin bridge to warfarin and has a
history of GIB. Started patient on Toprol XL 75mg daily. CKs
trended down after CHF exacerbation. This was believed to be
related to demand ischemia. TnT is difficult to assess in the
context of ARF. Started on amiodarone for rhythm control as
below.
- Continue Toprol XL 75mg, Valsartan 40mg [**Hospital1 **]
- Continue Aspirin 81mg daily
- Continue Imdur 30mg daily and Ranolazine 500mg [**Hospital1 **]
#. Pump: EF of 30-35%. Echo this admission showed moderate
regional left ventricular systolic dysfunction with near
akinesis of the distal half of the septum and anterior walls,
and distal inferolateral walls. The apex is dyskinetic and
aneurysmal. Patient was volume overloaded on exam initially,
but improved throughout admission. Was treated with gentle
diuresis with PO lasix after initially given IV lasix.
- Continue Lasix 20mg po daily
#. Rhythm: NSR s/p Afib with RVR causing worsening CHF.
Initially cardioverted unsuccessfully. Then received amiodarone
drip followed by 200mg PO TID and then converted to NSR. He
will continue with amiodarone 200mg PO BID after [**2204-3-9**].
- Continue Amiodarone 200mg TID until [**3-9**], continue [**Hospital1 **] regimen
for 2 weeks, then 200mg daily thereafter
- Continue Coumadin 1mg daily
- Check INR in 2 days. Goal 2-2.5.
#. Renal failure: Basline 1.3. Cr rose to 1.8 from a baseline
of 1.3 prior to admission and 1.4 on admission. Etiology likely
combination of HTN, contrast, and Lasix. At discharge his Cr is
1.7, and is expected to trend downwards.
Medications on Admission:
Amlodipine 10mg daily
Atenolol 25mg daily
Imdur 30mg daily
HCTZ 12.5mg daily prn
Valsartan 80mg [**Hospital1 **]
ASA 81mg daily
Lipitor 20mg QHS
Discharge Medications:
1. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Continue TID for two more days, then [**Hospital1 **] for two weeks,
then daily thereafter.
Disp:*60 Tablet(s)* Refills:*2*
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO QHS (once a day
(at bedtime)).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Valsartan 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0*
11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
please sit down prior to taking. please take every 5 minutes X 3
until pain free. If pain persists, please call EMS.
Disp:*60 Tablet, Sublingual(s)* Refills:*0*
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Outpatient Lab Work
Please have PT/PTT/INR drawn by home nursing on Monday, [**2204-3-12**]
and fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 26695**] at fax
1-[**Telephone/Fax (1) 14926**]. (Phone # is [**Telephone/Fax (1) 62**] if there are any
problems.)
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Coronary artery disease
.
Secondary: hyperlipidemia, hypertension, atrial fibrillation
Discharge Condition:
Afebrile, vitals stable.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**].
.
You were admitted for chest pain. You underwent a cardiac
catheterization which showed that several of your coronary
arteries had disease. Ultimately it was decided that your best
course of action is medical management of your coronary artery
disease. We adjusted your medications appropriately. You also
developed atrial fibrillation which was treated with
cardioversion and amiodarone. You were started on warfarin with
a goal INR of [**3-5**].5.
.
Please take your medications as ordered and make the following
changes:
1. Please stop your hydrochlorothiazide.
2. Please stop amlodipine.
3. Please start coumadin as directed, 1 mg daily.
4. Please continue amiodarone for your atrial fibrillation. Take
200 mg three times daily for 2 more days and then decrease to
twice daily for two weeks. Please then decrease to 200 mg daily.
5. Please stop atenolol and start toprol XL (metoprolol) 75 mg
daily.
6. Please continue imdur 30 mg daily.
7. Please decrease valsartan 40 mg twice per day.
8. Please increase lipitor to 40 mg daily.
9. Please continue furosemide (lasix) 20 mg daily.
.
Please attend your follow up appointments.
.
Please call your doctor or come to the emergency room if you
experience chest pain, shortness of breath, palpitations,
bleeding, passing out, or other concerning symptoms.
Followup Instructions:
Please follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on
[**2204-3-20**] at 9:40 am. Please call his office at
[**Telephone/Fax (1) 62**] if there is a problem with this appointment.
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2204-3-20**] 9:40
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1940**], within the next two weeks; they will contact you with
your appointment time. Please call Dr.[**Name (NI) 13540**] assistant,
[**Location (un) 13544**], at [**Telephone/Fax (1) 13545**] if you have not heard from her in the
next 1-2 days.
Please call the [**Hospital **] Clinic to set up an appointment to manage
your high blood sugars at ([**Telephone/Fax (1) 4847**].
Completed by:[**2204-4-6**]
|
[
"V10.46",
"428.0",
"V10.05",
"924.5",
"410.71",
"585.9",
"584.9",
"427.31",
"E888.9",
"414.01",
"428.23",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.57",
"37.22",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
14711, 14769
|
9609, 12112
|
280, 321
|
14909, 14936
|
5129, 6149
|
16351, 17324
|
3970, 4029
|
12308, 14688
|
14790, 14888
|
12138, 12285
|
6936, 8106
|
14960, 16328
|
4044, 5110
|
230, 242
|
349, 2745
|
2767, 3801
|
3817, 3954
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,354
| 105,671
|
34815
|
Discharge summary
|
report
|
Admission Date: [**2113-11-21**] Discharge Date: [**2113-12-4**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
[**2113-11-21**] - CABGx3(LIMA-LAD, SVG-OM, SVG-PDA). Aortic Valve
Replacement (21mm [**Company 1543**] Mosaic Ultra Porcine Valve)
Bronchoscopy
thoracentesis
History of Present Illness:
This 84 year old white female with long standing complaints of
exertional chest
pressure and dyspnea and a LBBB underwent a stress test today.
The stress
test was positive for complaints of chest pressure and negative
for EKG changes. Nuclear imaging showed no evidence of ischemia
or wall
motion abnormalities. She was sent to the emergency room for
evaluation and was treated for CHF on her CXR with Lasix.
She was then transfered to [**Hospital1 18**] for cardiac catheterization.
Past Medical History:
Hypothyroidism
Hyperlipidemia
Hypertension
Social History:
married and living with husband. Two children
live in triple [**Doctor Last Name **] above and below pt.
Family History:
noncontributory
Physical Exam:
Discharge:
VS T97.9 HR 69 SR BP 116/57 RR 22 O2sat 93% 2LNP
Neuro: A&Ox3. Non focal exam
Lungs- decreased BS at bases, occ. rhonchi.
Cor- RRR no murmur. Sternum stable, incision CDI
Abd: soft, NT/ND/+BS
Exts- trace edema, warm. palpable pulses
Pertinent Results:
[**2113-11-21**] 06:09PM UREA N-12 CREAT-0.7 CHLORIDE-112* TOTAL
CO2-26
[**2113-11-21**] 06:09PM WBC-16.1* RBC-2.77*# HGB-8.9*# HCT-26.1*
MCV-94 MCH-32.2* MCHC-34.2 RDW-12.8
[**2113-11-21**] 06:09PM PLT COUNT-146*
[**2113-11-21**] 06:09PM PT-14.4* PTT-38.4* INR(PT)-1.3*
[**2113-11-21**] 05:23PM GLUCOSE-126* LACTATE-3.4* NA+-139 K+-4.1
CL--111
[**2113-12-4**] 01:12AM BLOOD WBC-14.2* RBC-3.50* Hgb-10.8* Hct-32.6*
MCV-93 MCH-30.9 MCHC-33.2 RDW-14.6 Plt Ct-436
[**2113-12-4**] 01:12AM BLOOD Plt Ct-436
[**2113-11-28**] 03:25AM BLOOD PT-15.2* PTT-32.4 INR(PT)-1.3*
[**2113-12-4**] 01:12AM BLOOD Glucose-102 UreaN-26* Creat-0.7 Na-142
K-3.7 Cl-106 HCO3-30 AnGap-10
[**2113-11-21**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is mildly
depressed (LVEF= 40 - 45 %). Hypokinesis of the septum and
inferior walls is seen.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is severe aortic
valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient initally had moderate LV systolic depresson. An
infusion of epinephrine was started. LV systolic fxn returned to
mild depression. RV systolic fxn was good.
A prosthetic aortic valve is well-seated and functional. No leak
is seen. A residual peak gradient of 30 mmHg is seen.
Aorta intact.
[**Known lastname **],[**Known firstname **] E [**Medical Record Number 79735**] F 84 [**2029-2-10**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2113-12-1**] 7:19
AM
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with
REASON FOR THIS EXAMINATION:
s/p thoracentesis evaluate re-expansion?
Final Report
REASON FOR EXAM: Followup pleural effusion post left
thoracentesis and
pulmonary edema.
Comparison is made with prior studies of [**11-29**] and 13.
Low lung volumes are unchanged. Moderate cardiomegaly is table.
Mild-to-
moderate pulmonary edema is unchanged. Left lower lobe
retrocardiac opacity
has increased likely due to atelectasis. There is a small amount
of left
pleural effusion. NG tube tip is out of view below the
diaphragm. Sternal
wires are aligned. Left subclavian catheter tip is in the SVC.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: FRI [**2113-12-1**] 2:33 PM
Brief Hospital Course:
Ms. [**Known lastname 69335**] was admitted to the [**Hospital1 18**] on [**2113-11-21**] for surgical
management of her aortic valve and coronary artery disease. She
was taken directly to the operating room where she underwent
coronary artery bypass grafting and an aortic valve replacement.
Please see operative note for details. She weaned from bypass on
epinephrine and nitroglycerine in stable condition. She was
transferred to the ICU.
She was acidotic and treated with fluid resuscitation, Levophed
and Milrinone. hemodynamics stabilized and lactates cleared by
the morning after surgery. Pressors were weaned and discontinued
over the first three days. She was extubated on the second day
after surgery, but required reintubation for fatigue and
increased work of breathing. Amiodarone was utilized for AF
control with eventual restoration of SR .A chest CT was done to
evaluate for effusions. A small to moderate Rt effusion was and
a thoracentesis yielded 400cc of fluid. Bronchoscopy on [**11-27**]
for small amounts of white secretions.
Diuresis was continued and CV remained stable. AcE inhibition
and beta blockade were begun and advanced to adequate levels.
The ventilator was weaned and she was again extubated on [**11-28**].
BiPAP was utilized nocturnally and aggressive pulmonary toilet
was performed. She improved and BiPAP was stopped after [**12-1**].
A speech and swallowing evaluation was done and she was cleared
for ground solids and thin liquids, to be advanced as tolerated.
With strength improving and pulmonary status stable she was
ready for discharge to a rehabilitation facility.
Her CXR shows low volumes, consistent with poor inspiratory
effort, but no effusions or infiltrates. Labs are stable.
Follow up requirements,medications and precautions are outlined
in the discharge paperwork.
Medications on Admission:
lipitor 20', levothyroxine 150', mevacor 20', lopressor 50',
ASA 81', pletal 100'
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
2. Magnesium Hydroxide 400 mg/5 mL Suspension [**Month/Year (2) **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. Levothyroxine 50 mcg Tablet [**Month/Year (2) **]: Three (3) Tablet PO DAILY
(Daily).
4. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: 2.5 mg Inhalation Q4H (every 4 hours).
7. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) IH
Inhalation Q6H (every 6 hours).
8. Fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
11. Captopril 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2
times a day).
13. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
14. Potassium Chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) PO once a
day.
15. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: see
sliding scale Subcutaneous AC & HS: 120-160:2units SQ
161-200:4units SQ
210-240:6units SQ
241-280:8unitsSQ.
16. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
aortic stenosis
coronary artery disease
s/p aortic valve replacement & coronary artery bypass grafts
[**2113-11-21**]
Hypercholesterolemia
hypertension
Hypothyroidism
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month ([**Telephone/Fax (1) 170**])
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) 1637**] in [**2-19**] weeks ([**Telephone/Fax (1) 14655**])
Completed by:[**2113-12-4**]
|
[
"287.5",
"414.01",
"E878.8",
"272.0",
"276.2",
"424.1",
"244.9",
"E849.7",
"401.9",
"511.9",
"428.0",
"458.29",
"518.5",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.12",
"96.6",
"96.72",
"96.04",
"99.04",
"34.91",
"36.15",
"33.23",
"88.72",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
7946, 7961
|
4171, 6004
|
284, 445
|
8172, 8179
|
1465, 3242
|
8957, 9253
|
1164, 1181
|
6137, 7923
|
3282, 3305
|
7982, 8151
|
6030, 6114
|
8203, 8934
|
1196, 1446
|
230, 246
|
3337, 4148
|
473, 960
|
982, 1026
|
1042, 1148
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,017
| 193,492
|
40312
|
Discharge summary
|
report
|
Admission Date: [**2200-10-3**] [**Month/Day/Year **] Date: [**2200-10-7**]
Service: SURGERY
Allergies:
Epinephrine / Novocain / Latex
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
[**2200-10-4**] Embolization w/ 4 coils & Gelfoam slurry of the anterior
branch of the right internal iliac artery
[**2200-10-7**] Interrogation of pacemaker
History of Present Illness:
86 year old female who presented to the ED
as a transfer from [**Hospital **] Hospital. She was in her usual state
of health until she tripped and fell on
her right buttock while walking. She immediately had
right hip and buttock pain. Taken to [**Hospital **] Hospital where she
was found to have a right superior and inferior pubic ramus
fracture. She was discharged to rehab. On morning of admission
she nearly
syncopized and was taken back to [**Hospital **] Hospital where her SBP
was in the 80's, Hct 25, and INR 3. She was given 5 mg of po
Vitamin K, 2 FFP, and transferred to [**Hospital1 18**] for further
managment. Upon arrival, her SBP was initially in the 110's but
quickly dropped to 80's.
Past Medical History:
Aortic insufficiency s/p aortic valve replacement; AFib (on
Coumadin)
PSH: bovine aortic valve [**5-5**] ([**Hospital1 1774**]), pacemaker, hysterectomy,
ex-lap for sledding trauma as a child
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
PE: 98.2 74 106/62 --> 84/60 16 99% 2L
A&O x 3, NAD
PERRL, EOMI, atraumatic
Neck supple
RRR
CTAB
Abdomen soft, nondistended, severely tender to palpation
suprapubically just to the right of midline. Palpable firm
hematoma. + ecchymosis over lateral R. hip.
LE warm, no edema
Ext: Strength full throughout. Limited due to pain in RLE.
Pertinent Results:
[**2200-10-3**] 10:53PM HGB-8.2* calcHCT-25
[**2200-10-3**] 10:32PM GLUCOSE-123* UREA N-17 CREAT-1.1 SODIUM-137
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14
[**2200-10-3**] 10:32PM WBC-7.9 RBC-2.46* HGB-7.8* HCT-23.1* MCV-94
MCH-31.6 MCHC-33.6 RDW-17.5*
[**2200-10-3**] 10:32PM PLT COUNT-154
[**2200-10-3**] 10:32PM PT-23.4* PTT-30.2 INR(PT)-2.2*
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
IMPRESSION:
1. Large hematoma within the lower abdomen/upper pelvis with
evidence of
active extravasation. Injury to the internal pudendal artery or
external
pudendal artery may cause a bleed in this region.
2. Interval increase in perihepatic, perisplenic and
intraperitoneal fluid of intermediate density and compatible
with hemorrhage. Although this may be related to the pelvic
hematoma and active extravasation, occult mesenteric or bowel
injury cannot be excluded.
3. Right superior ramus and left sacral ala fractures as above.
Brief Hospital Course:
She was admitted to the ACS service and taken to interventional
radiology for embolization of her right internal iliac artery.
There were no procedural complications. Her hematocrits while
they remain below normal have been stable without any
significant drop from the already below normal levels (last Hct
24.4). Hemodynamically she has been stable with blood pressures
ranging between 102-128 systolic.
She was also evaluated by Orthopedics for her pubic rami
fractures, these were managed non operatively. She may weight
bear as tolerated and will follow up in 2 weeks in [**Hospital 1957**] clinic
for repeat xray imaging studies.
It was noted on telemetry that she had several runs of
asymptomatic NSVT. EPS/Cardiology was consulted. Her pacer was
interrogated and found to be functioning normally. The
ventricular detection was changed to 160 BPM given the episode
of NSVT; Lopressor 12.5 mg [**Hospital1 **] was also recommended to be
started.
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay.
Medications on Admission:
coumadin 6' (was at 4, but recently been increasing dose),
lisinopril, tramadol, gabapentin, zolpidem
[**Hospital1 **] Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
2. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 12.5 Tablets PO BID (2
times a day): hold for SBP <110; HR <60.
9. tramadol 50 mg Tablet Sig: [**12-28**] Tablet PO every six (6) hours
as needed for pain.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital 5682**] Rehabilitation and Skilled Nursing Center - [**Hospital1 **]
[**Hospital1 **] Diagnosis:
s/p Fall
Pubic ramus fracture
Right internal iliac artery bleeding
Non-sustained ventricular tachycardia
[**Hospital1 **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Hospital1 **] Instructions:
Your Coumadin is being withheld because of the bleeding blood
vessel in your pelvis. It is recommended that you follow up with
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab for
restarting this.
Followup Instructions:
Follow up with your primary cardiologist (Dr. [**First Name (STitle) **] after
[**First Name (STitle) **] from rehab for your pacemaker and for restarting your
Coumadin dosing. You or your family will need to call for an
appointment.
Follow up in [**Hospital 1957**] clinic in 2 weeks for your pubic ramus
fracture; call [**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2200-11-4**]
|
[
"V45.01",
"V58.61",
"958.2",
"958.4",
"808.2",
"459.0",
"E885.9",
"427.31",
"V43.3",
"427.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.45",
"39.79",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
2800, 3859
|
258, 418
|
1818, 2777
|
5926, 6328
|
1385, 1402
|
3886, 3990
|
1417, 1799
|
210, 220
|
5213, 5320
|
4020, 5183
|
446, 1152
|
5498, 5634
|
5348, 5483
|
1175, 1369
|
5665, 5903
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,995
| 113,576
|
5939
|
Discharge summary
|
report
|
Admission Date: [**2194-9-24**] Discharge Date: [**2194-9-24**]
Date of Birth: [**2143-1-30**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Darvon / Gabapentin / Mucinex / Robitussin /
Lyrica / Lipitor / Oxycontin / Codeine
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Colonic ischemia
Major Surgical or Invasive Procedure:
Exploratory laparotomy [**2194-9-24**]
History of Present Illness:
51F s/p CRT on [**2194-6-5**] with h/o persistent abdominal pain and
associated nausea, diarrhea and ongoing c.diff w/ multiple
recent admissions now presented to [**Hospital3 417**] Hospital from
[**Hospital **] Rehab late evening [**2194-9-23**] w/ acute abdominal pain and
h/o recent coffee-ground emesis w/ leukocytosis peak at 25.2 w/
60% bands and lactate of 13.7 initially and then 9.3, also
hypotensive on high-dose levophed on transfer to [**Hospital1 18**]. CT
abd/pelv reviewed here demonstrated colonic distension/dilation
w/ pneumatosis. Pt arrived intubated and sedated w/ abd TTP,
still requiring vasopressor support. She was taken to OR
emergently for ex-lap and possible total abdominal colectomy.
Past Medical History:
PMH: ESRD d/t chronic glomerulonephritis now s/p cadaveric renal
transplant [**2194-6-5**], hypercholesterolemia, HTN, GERD, restless leg
syndrome, persistent C. diff infection
PSH: failed living related kidney transplant [**2187-1-30**], cadaveric
renal transplant [**2194-6-5**], RUE AV fistula with multiple revisions
for aneurysm s/p removal and wound revision, PD catheter
placement
Social History:
Lived at home with husband and children prior to recent surgery
and has been in/out of rehab since.
Has smoked [**12-7**] PPD for the last 30 years but despite plans to
quit after her transplant she has not.
Denies past or current alcohol or illicit/recreational drug use.
Family History:
Mother had DM Type 2
Brother had brain aneurysm
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Levoph 0.25, Fent 200, Versed 4
O: T: 100.1 HR: 119 BP: 103/49 RR: 33 O2Sats: 100%
CMV 100%/450x18/5
Gen: Intubated, sedated.
Neck: Supple.
Lungs: coarse bilaterally.
Cardiac: RRR.
Abd: no BS, mildly firm, +diffuse TTP, mild distension.
Extrem: no edema.
Pertinent Results:
[**2194-9-24**] 12:47PM BLOOD WBC-5.4# RBC-3.00* Hgb-9.7* Hct-29.0*
MCV-97 MCH-32.4* MCHC-33.6 RDW-21.3* Plt Ct-179
[**2194-9-24**] 12:47PM BLOOD PT-19.7* PTT-37.0* INR(PT)-1.8*
[**2194-9-24**] 12:47PM BLOOD Fibrino-415*
[**2194-9-24**] 12:47PM BLOOD Glucose-69* UreaN-44* Creat-1.5* Na-138
K-3.3 Cl-104 HCO3-17* AnGap-20
[**2194-9-24**] 01:48PM BLOOD Glucose-70 Lactate-5.0* Na-138 K-3.3*
Cl-110
[**2194-9-24**] 01:13PM BLOOD Lactate-5.3*
[**2194-9-24**] 12:47PM BLOOD ALT-43* AST-133* LD(LDH)-471*
AlkPhos-120* TotBili-0.9
[**2194-9-24**] 12:47PM BLOOD Albumin-2.5* Calcium-7.8* Phos-6.2*#
Mg-2.5
[**2194-9-24**] 01:48PM BLOOD Type-ART pO2-283* pCO2-35 pH-7.29*
calTCO2-18* Base XS--8 Intubat-INTUBATED Vent-CONTROLLED
CT abd/pel (OSH, no official report - reviewed here w/ Dr.
[**Last Name (STitle) **] - demonstrated diffusely distended colon w/ bowel wall
thickening and ?pneumatosis but no obvious free fluid/air
Brief Hospital Course:
Patient arrived in SICU on cardiopulmonary support (levophed,
vent, sedated). Outside chart reviewed including CT abd/pel w/
Dr. [**Last Name (STitle) **]. Patient w/ clinical and radiographic signs of
colonic ischemia. Decision was made to take patient emergently
to OR for exploratory laparotomy w/ likely total abdominal
colectomy. [**Name (NI) 1094**] mother [**First Name8 (NamePattern2) **] [**Name (NI) 2716**]) who is one of her
healthcare proxies (husband is primary but has hearing disorder)
was contact[**Name (NI) **] via cell phone for operative consent which was
obtained. Intraoperative findings were consistent with
pan-necrosis of small and large bowel - a non-survivable injury
and thus, patient's abdomen was closed and she was returned to
the SICU where after discussions w/ the family and surgical
staff, she was made CMO. She was removed from all medications
except morphine for comfort. She eventually expired at 10:28pm.
Her case was declined by the medical examiner but the family
requested and consented for an autopsy.
Medications on Admission:
fentanyl patch 25mcg per hour, D5NS w/ bicarb, sterile water
250cc PO q6h, vancomycin 250mg PO q6hr, flagyl 500mg IV q6h,
Jevity 1.5 cal TF, zofran PRN, tramadol 50mg q6h prn,
ergocalciferol 50,000units PO weekly, methylphenidate 5mg PO
BID, azathioprine 50mg PO daily, valcyte 450mg daily, protonix
40mg daily, citalopram 10mg daily, dapsone 100mg daily,
levothyroxine 50mcg dialy, metoclopramide 10mg before meals and
bedtime, tacrolimus 2mg q12h, clonazepam 0.5mg nightly,
mirtazapine 15mg daily, acetaminophen 650mg q6h prn, albuterol
sulfate 2 puffs INH q4h prn, simethicone 80mg q8h prn,
ipratropium 2 puffs INH q6h prn
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Pan-necrosis of small and large bowel
ESRD d/t chronic glomerulonephritis s/p cadaveric renal
transplant [**2194-6-5**]
hypercholesterolemia
HTN
GERD
restless leg syndrome
persistent C. diff infection
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
|
[
"V42.0",
"272.0",
"401.9",
"557.0",
"530.81",
"008.45",
"333.94"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4970, 4979
|
3207, 4262
|
374, 415
|
5224, 5234
|
2258, 3184
|
5290, 5301
|
1881, 1931
|
4938, 4947
|
5000, 5203
|
4288, 4915
|
5258, 5267
|
1946, 1960
|
318, 336
|
443, 1161
|
1975, 2239
|
1183, 1574
|
1590, 1865
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,341
| 113,960
|
22884
|
Discharge summary
|
report
|
Admission Date: [**2169-6-16**] Discharge Date: [**2169-6-24**]
Date of Birth: [**2105-3-13**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Admitted for reversal of colostomy
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy
2. takedown of colostomy.
History of Present Illness:
64 y/o male who underwent a CABG on [**2168-6-17**]. His post op
course was complicated by a GI bleed, requiring takeback to the
OR for ex-lap and sigmoid and rectal resection with creation of
end colostomy. He has done well since the time of surgery and is
now requesting colostomy reversal. He denies chest pain,
shortness of breath. He was recently cleared by cardiology for
the procedure.
Past Medical History:
CAD s/p MI, PTCA/stent to LAD
4 vessel CABG [**2168-6-17**] c/b:
-postoperative Atrial fibrillation s/p cardioversion.
-acute cholecystitis s/p perc cholecystostomy and
cholecystectomy
-pericardial effusion
-ventilator associated pneumonia
-lower GI bleed s/p IR coiling then s/p rectal resection
-g-tube postoperatively
CHF
Sigmoid and partial rectal resection [**2168-6-28**] with end colostomy
Type 1 IDDM
Gastroparesis
Rheumatic fever as child
OSA
Rheumatoid arthritis
Chronic LBP
BPH
GERD
Diverticulitis
Social History:
Married, no tob, EtOH, or drugs.
Lives with wife in [**Name (NI) 1110**]. Quit smoking [**2152**].
Obese.
Family History:
CAD
Physical Exam:
Post Op:
VS: 100.9, 121 (sinus tach), 116/60, 28, 97% 4L NC
Gen: A+O, MAE
Card: RRR
Lungs: few crackles
Abd: Obese, incision c/d/i, 2 JP bulbs in place
Extr: 1+ edema
Pertinent Results:
POD 1: [**2169-6-17**]
WBC-32.1*# RBC-4.23* Hgb-10.5* Hct-33.0* MCV-78* MCH-24.8*
MCHC-31.8 RDW-16.8* Plt Ct-231
Glucose-175* UreaN-11 Creat-0.8 Na-137 K-4.4 Cl-108 HCO3-20*
AnGap-13
Calcium-7.6* Phos-2.3* Mg-1.8
Brief Hospital Course:
64 y/o male who presented for reversal of his colostomy and also
hernia repair. He underwent exploratory laparotomy, takedown of
colostomy and ventral hernia repair.
He was taken to the OR by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. In summary he
underwent a ventral hernia repair as well as succesful reversal
of the pre-existing colostomy. He was extubated in the OR.
Please see the operative note for surgical detail.
He was transferred to the surgical ICU for close mom[**Name (NI) **] of
blood pressure and blood sugar. He was tachycardic and
hypertensive maintained on IV lopressorHe was initially on an
insulin drip. He was also started on Levaquin and Flagyl due to
the abdominal surgery.
Despite the antibiotics he persisted with fevers to 101.2
through POD 3. Blood cultures from [**6-17**] grew MRSA and a swab
taken [**Last Name (un) 834**] the wound was also MRSA. He was continued on
Vancomycin and will continue that for an additional two weeks.
Other antibiotics were d/c'd.
The abdominal incision was opened and a wound VAC placed on [**6-22**]
(POD 7) The wound is very deep due to patients obese abdomen.
He started to defervesce by POD 7 and remained afebrile.
He was seen by PT who assessed his needs as amenable to a rehab
facility
A PICC line was placed on [**6-23**] for continued requirement for
IV antibiotics.
Medications on Admission:
asa 81, ativan 2mg hs, atorvaastatin 80', combivent, detrol 4mg,
ezetimibe 10', folic acid, insulin - lantus 80U am, 30U bedtime,
iron, methotrexate 2.5mg', toprol 25', calcium
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-18**]
Puffs Inhalation Q6H (every 6 hours) as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed.
13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 2 weeks.
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous DAILY (Daily) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Ileostomy needed takedown and reanastamosis of intestines.
Status post left colonic resection for bleeding.
Discharge Condition:
stable to rehab
Discharge Instructions:
Patient requests transfer to [**Hospital1 **] [**Location (un) 47**] for any
emergency situation as his primary physicians are affiliated
with that institution.
Call your doctor or return to the Emergency Department if
develop fever 101 or greater, any increased redness or swelling
around your incisions, worsening of nausea, you begin vomiting,
you are passing significant blood or stool from the rectum or
you develop any other concerning symptoms.
.
Do not drive or drink alcohol while taking narcotic pain
medications. Take a stool softener while taking narcotics.
.
No heavy lifting.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **]. Please call to make an
appointment: ([**Telephone/Fax (2) 3618**]Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 2310**], MD
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2169-8-17**] 4:30
Completed by:[**2169-6-24**]
|
[
"250.00",
"553.21",
"272.4",
"V45.81",
"569.89",
"427.31",
"714.0",
"414.00",
"790.7",
"V55.3",
"530.81",
"041.11",
"V09.0",
"785.0",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.24",
"53.51",
"93.59",
"46.52"
] |
icd9pcs
|
[
[
[]
]
] |
4829, 4903
|
1909, 3277
|
305, 359
|
5055, 5073
|
1672, 1886
|
5714, 6020
|
1465, 1470
|
3505, 4806
|
4924, 5034
|
3303, 3482
|
5097, 5691
|
1485, 1653
|
231, 267
|
387, 781
|
803, 1325
|
1341, 1449
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,232
| 178,070
|
31314
|
Discharge summary
|
report
|
Admission Date: [**2179-11-18**] Discharge Date: [**2179-12-30**]
Date of Birth: [**2114-8-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
[**First Name3 (LF) **]/diarrhea
Major Surgical or Invasive Procedure:
IJ placement
History of Present Illness:
65 year old man with hx of CHF (EF 30%), CAD (with NSTEMI on
[**9-10**] s/p cath on [**2179-9-19**] showing 3VD s/p BMS to LMCA, LAD, POBA
of OM), PVD, COPD, h/o mesenteric ischemia s/p bowel resection
in [**7-/2179**], MRSA pneumonia, initially p/w [**Year (4 digits) **]/diarrhea on
[**2179-11-18**]. In the [**Hospital1 **] [**Name (NI) **], pt afebrile, but SBP 50s. Pt's pressure
was responsive to aggressive fluids. Pt also had a leukocytosis
(wbc 36) and positive U/A, and was started on vanc/levo/flagyl.
Noted to have rising CEs. In the ED, the patient developed VT
arrest in setting of sepsis and a Mg 0.8. Magnesium was
repleted, and he received one shock with recovery of Normal
Sinus rhythm. During the code the pt was intubated and sent to
the MICU. He was subsequently extubated on [**2179-11-19**]. Of note,
CT scan done in ED showed pancolitis.
In the MICU the pt was noted to have loose stools. He was
diagnosed as sepsis/hypovolemia. He was given aggressive fluids
via CVL. Pt briefly on lidocaine drip from the ED, but never
required pressors. C diff from [**11-18**] was positive. Pt's abx
changed to po vanc/flagyl alone. Pt extubated on [**11-19**]. He
required a lasix drip [**Date range (1) 46801**] for fluid overload from
resuscitation.
He was then transfered to medicine for further management. On
the medicine floor he became dyspneic with O2 requirement. On
[**11-24**] Lasix was held for hypotension and dyspnea worsened.
Because of this worsening of dyspnea CE were drawn and showed
elevated Trop-T to 3.12 and CK of 15 c/w NSTEMI. Heparin gtt
was started. On [**11-25**] BP stablized and pt has responded with
increased urine output to Lasix IV bolus with Metolazone. He
was transferred to [**Hospital1 1516**] today for management of NSTEMI and
better management of fluid status.
Past Medical History:
PVD- s/p aorto [**Hospital1 **] fem bypass
DM
Bladder CA
COPD
s/p cholecystectomy
Aorto [**Hospital1 **] Fem Bypass
mesenteric ischemia s/p stenting of SMA
CAD with 3 vessel disease on cath [**2179-8-4**]
duodenal angioectasia
respiratory failure
MRSA pneumonia
Social History:
Pt has 75 pack/year smoking history, quit during last
hospitalization, previous ETOH use about 6-12 beers/week. He is
a retired highway heavy equipment operator, currently lives at
[**Hospital3 **].
Family History:
Family history significant for CAD, brother with MI at age
younger than 50.
Physical Exam:
MICU Physical Exam:
Vs- 100/50 98.0 95 20 100% on PS 10/5, 50% FiO2
Gen- intubated, arousable, not sedated, appears comfortable
Heent- MMM, anicteric, symmetric, PERRL
Neck- supple, could not assess JVP
Cor- regular, tachy, distant heart sounds could not apprec.
murmur
Chest- expiratory wheeze with vent sounds. Decreased at bases
Abd- soft, open surgical wound with minimal purulent drainage
proximally. Pos BS. Tender along wound.
Ext- no c/c/e. Pneumoboots on. Bounding femoral pulses with
scars from prior bypass surgeries.
Neuro- Appears alert , though cannot fully assess orientation
due to endotracheal tube.
Floor: D/C Physical Exam
Vitals; 98.8 104/58 88 18 97% on 2l
Gen: NAD, comfortable
HEENT: MMM, no LAD, EOMi, anicteric
Neck: supple
Card: RRR
Chest: CTAB, no wheezing/crackles
Abd: soft, NT/ND. dressing in place (c/d/i) over open surgical
wound
Ext: no c/c/e. muscle wasting in bilateral lower extremities
Neuro: alrt, oriented
Skin: stage 2 sacral decubitus ulcer
Pertinent Results:
Lab results on Admission:
[**2179-11-18**] 12:49AM BLOOD WBC-36.2*# RBC-3.48* Hgb-10.8* Hct-32.2*
MCV-93 MCH-31.2 MCHC-33.7 RDW-18.5* Plt Ct-530*
[**2179-11-18**] 12:49AM BLOOD Neuts-83* Bands-3 Lymphs-3* Monos-11
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2179-11-18**] 04:18PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Burr-1+
[**2179-11-18**] 12:49AM BLOOD PT-16.4* PTT-30.1 INR(PT)-1.5*
[**2179-11-18**] 12:49AM BLOOD D-Dimer-5720*
[**2179-11-18**] 05:10AM BLOOD Fibrino-597*#
[**2179-11-18**] 12:49AM BLOOD Glucose-43* UreaN-25* Creat-1.5* Na-138
K-4.4 Cl-103 HCO3-19* AnGap-20
[**2179-11-18**] 12:49AM BLOOD CK(CPK)-22*
[**2179-11-18**] 12:49AM BLOOD CK-MB-NotDone cTropnT-0.28*
[**2179-11-18**] 05:10AM BLOOD Phos-2.8# Mg-0.8*
[**2179-11-18**] 01:10PM BLOOD Type-ART FiO2-100 pO2-440* pCO2-42
pH-7.10* calTCO2-14* Base XS--16 AADO2-233 REQ O2-47
Intubat-INTUBATED
[**2179-11-18**] 03:20PM BLOOD Type-ART pO2-335* pCO2-32* pH-7.28*
calTCO2-16* Base XS--10 Intubat-INTUBATED
[**2179-11-18**] 12:38AM BLOOD Lactate-4.7*
[**2179-11-18**] 03:45AM BLOOD Glucose-153* Lactate-3.0*
[**2179-11-18**] 03:20PM BLOOD freeCa-1.05*
Discharge labs:
IMAGING:
[**11-18**] CT ABD:
IMPRESSION:
1. Findings consistent with pancolitis, significantly increased
in severity and extent compared to the prior study. This could
be due to an inflammatory or infectious process, including C.
Difficile colitis.
2. Large bilateral pleural effusions.
3. Diffuse anasarca.
[**11-18**] CXR:
IMPRESSION:
1. Appropriate placement of ET and NG tubes.
2. Increased interstitial opacities bilaterally consistent with
fluid overload.
3. More focal airspace opacities involving the right lung may
represent asymmetric pulmonary edema or pneumonia.
4. Persistent opacification of the right cardiophrenic angle may
represent right middle lobe collapse.
[**11-18**] EKG:
Baseline artifact. Sinus rhythm. Marked left axis deviation.
Right
bundle-branch block. Early R wave progression. ST-T wave
abnormalities. Since the previous tracing of [**2179-10-1**] ST-T wave
abnormalities may be improved or there is pseudonormalization
[**11-19**] ECHO:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate to severe global left ventricular
hypokinesis (LVEF = 30 %) with regional variation: the inferior
and posterior walls are more hypokinetic than the rest of the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size is normal. Right ventricular systolic
function is borderline normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**11-24**] CT Chest:
IMPRESSION:
1. Interval worsening in now large bilateral pleural effusions
(compared to CT [**2179-11-18**], but similar to CT [**2179-9-29**]), without
evidence of loculated component. Peripheral interstitial septal
thickening suggests congestive failure as part of the cause for
the effusions.
2. Debris dependently within the trachea. This finding was
called to Dr. [**Last Name (STitle) **] on [**2179-11-25**]
[**11-26**] CXR:
FINDINGS: In comparison with the study of [**11-24**], there is again
moderate-to- severe pulmonary edema with substantial pleural
effusions bilaterally and enlargement of the cardiac silhouette.
Right IJ catheter again extends to the lower portion of the SVC.
ECHO [**12-23**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
inferior akinesis with moderate hypokinesis of the other LV
segments, c/w multivessel coronary artery disease or systemic
process. Overall left ventricular systolic function is
moderately depressed (LVEF= 30%). Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Moderate regional and global left ventricular
systolic dysfunction. Moderate mitral regurgitation.
Compared with the prior study (images reviewed) of [**2179-12-3**],
the findings are similar.
[**11-29**] C. Cath:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Systemic hypotension.
3. Low filling pressures.
4. Successful stening of the LM with a CYPHER DES.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt
[**2179-12-30**] 06:30AM 11.0 3.32* 10.7* 32.4* 98 32.0 32.9 16.5*
393
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2179-12-30**] 06:30AM 126* 21* 1.1 137 4.5 104 31 7*
Brief Hospital Course:
65 year-old man with 3-vessel CAD initially admitted for Cdiff
colitis complicated by polymorphic VT arrest on initial
presentation, NSTEMI and then STEMI s/p L main stenting,
systolic CHF with acute exacerbations, hospital acquired
pneumonia with sepsis and GIB.
.
# Cardiac arrest / Ischemia: In the ED a 'code blue' was called
when he became unresponsive and was noted to have a polymorphic
VT vs. torsades rhythm. He was resuscitated with
defibrillation, epinephrine, and started on a lidocaine drip.
The etiology of the arrest is likely due to severe electrolyte
derangements, including a magnesium of 0.8 that was in the
process of repletion. This was likely complicated by cardiac
ischemia from sepsis/hypotension. Cardiac enzymes were trended
and were markedly elevated as expected after defibrillation and
troponin reached a peak of 1.95 and then trended downward. He
was initially placed on aspirin , plavix and atorvastatin 80mg
and later re-started on metoprolol as tolerated by his blood
pressure. The patient was treated in the MICU and transferred
to the Medicine team. While on the medical floor he developed
hypotension and dyspnea. Cardiac Enzymes were again drawn and
showed an increased troponin to 3.12, up from 1.52 five days
prior. He was started on a heparin drip and transferred to the
[**Hospital1 1516**] Cardiology service for management on his NSTEMI and for
better managment of his fluid status. Troponin peaked at 3.58
and trended down. The Heparin drip was stopped after 48 hours.
He was chest pain free while on the Cardiology service. On
[**11-29**], pt had an episode of hypotension with SBP 84. An EKG was
done which showed marked TWI in V2-V4 and ST elevations in
II,III and AVF. Pt went to cath lab and underwent successful
stening of the LM with a CYPHER DES. Pt was hypotensive
peri-operatively, and recovered to the CCU for 24 hours. He was
briefly on a dopamine gtt but this was quickly weaned. He was
then transferred to the cardiology floor and was subsequently
stable from a cardiac standpoint. Pt needs to continue on
Aspirin and Plavix at all times. On the medicine floor pt had
intermitted episodes of increased HR (see atrial tachy below) as
well as episodes of hypotension (unrelated to tachyarrythmias),
see below.
.
# Afib/Atach: Pt w/ VT code upon presentation. Recurrent runs
of atrial tachycardia to 140s/150s, self resolving, but w/
occasional cp. cards c/s, recommended no albuterol to decrease
adrenergic drive, aggressive pain control, inc metoprolol to 50
[**Hospital1 **] (from 25 tid),and change captopril to lisinopril 10. the
metorpolol/lisinopril were subsequently d/ced due to increasing
number of episodes of asympt hypotension w/ SBP in 70s.
metoprolol currently restarted at 12.5bid, lisinopril restarted
[**12-29**].
.
# Asymptomatic hypotension: pt triggered multiple times on floor
for SBP 70-80. Pts bp tends to be low (85 to 110s).
asymptomatic during events. lisinopril decreased and eventually
d/ced. metoprolol decreased to 12.5 in an attempt to normalize
BP. repeated full workups, last on [**12-23**] w/ cxr (improved),
blood cx(NGTD), [**Last Name (un) 104**] stim borderline (low baseline, but response
to cosyntropin). [**12-24**] Starting on 2d 100 hydrocortisone, then
5mg prednisone daily to continue. [Note, on admission to micu
patient was on 5 mg po prednisone for unknown reason. Pt got
stress dose steroids in micu, which were subsequently d/ced on
floor. Restarted at 5mg qdaily given persistent borderline BPs,
though asymptomatic
.
# Sepsis: At presentation Mr. [**Known lastname **] had evidence by labs,
history, and imaging of a severe c.dif colitis, which was
confirmed by laboratory results. He has been treated with PO
flagyl and vancomycin for a two week course, transitioned to
vancomycin po taper. Other possible sources could be his UTI or
his abdominal wound / recent surgery. He was resuscitated with
~6L IVF in the ED, and his lactate trended downward. Stress
dose steroids were started in the icu, d/ced on the floor. He is
being treated for the C.diff with PO Vancomycin to complete a 14
day course free of other abx with vanco taper, 3d at tid, 5d at
[**Hospital1 **], 5 d more qdaily prior upon discharge. The [**Hospital 228**]
hospital course was also complicated by hospital acquired pna w/
+ resistant acinobacter now s/p 7d course tobra, 10d course
vanc/zosyn. cough/sob resolved.
.
# Left Ischemic Optic neuropathy-Pt reported poor vision in left
eye [**11-29**] initially and had reported this had been ongoing for
the few days prior. However this intial complaint of vision
change was in the context of a STEMI and pt quickly went to
cath; thus upon review of systems when patient came back from
cath, pt reported poor vision in both eyes, Left>right.
Patient appeared to have complete loss of vision in the left eye
and there was a concern for embolic stroke. An MRI/MRA was done
which did not show evidence of embolic dz or stroke. Opthamology
consulted and felt pt likely has ischemic damange to optic nerve
likely [**2-5**] hypotensive episodes. No further intervention was
needed other than to maintain a stable blood pressure. The pt
will need f/u with neuro-opthamology as outpt. ([**Telephone/Fax (1) 5120**]
.
# Respiratory failure: Patient was intubated during code
situation, extubated [**11-19**]. Extubation c/b acute on chronic
CHF. Subsequent intubation in the context of hospital acquired
pneumonia and sepsis. Now on 2L O2. Stable. Needs continous
aggressive chest PT.
.
# CHF: Acute on chronic CHF exacerbation. Appeared slightly
fluid overloaded in the setting of sepsis. A transthoracic echo
revealed an LVEF 30% He successfully underwent diuresis with
improvement in pulmonary symptoms. Euvolemia maintained,
autodiuresing, and gentle diuresis/hydration as necessary. home
lasix d/ced as pt has not been volume overloaded. [**2-5**]
hypotension, metoprolol decreased to 12.5 [**Hospital1 **], lisinopril to
2.5mg qdaily
.
# COPD: He has a history of copd with long smoking history. He
was on albuterol, ipratropium and systemic steroids. Albuterol
d/ced [**2-5**] cardiac recs that it may be contributing to patients
runs of atrial tachycardia. Systemic steroids not continued
after icu course. Acetylcysteine added to regimen, aggressive
chest PT and inspirative spirometry.
.
# DM2: He was on an insulin sliding scale and long-acting
insulin. ISS continued in hospital (no long acting [**2-5**]
inconsistent eating habits) with poor control of sugars.
Restarted low dose lantus on discharge with ISS, which will be
adjusted at rehab.
.
# Mesenteric ischemia: His small bowel resection was in [**Month (only) 205**]
[**2179**], and his abdominal wound was closed shortly thereafter.
The wound itself appears to okay, though there is some increased
purulence at the proximal aspect. Dr.[**Name (NI) 15146**] team evaluated
the wound and thought it was healing well. Patient was followed
by the wound care nurse throughout his hospital stay.
.
# GIB: Pt w/ melanotic Stools and known UGI AVMs, considered
likely source. no EGD required (unless pt rebleedsand becomes
unstable) as unlikely to be of benefit. Pts HCT remained stable
with a plan to transfuse PRBCs to HCT 30 given recent myocardial
ischemia, stools guaiaced (no rebleed) and pt continued on
pantoprazole. 1u prbcs on [**12-22**] and 12/23 [**2-5**] hct<30, with
occasional guaiac positive stools. Will get CBCs at rehab with
pRBCs fpr hct<30.
.
# Urinary Retention:
[**12-17**] pt w/ no UOP x8hrs s/p foley removal. bladderscan >500cc.
foley reinserted. flomax started.
[**12-20**] +UA, cx positive for yeast. no tx at this time except
foley d/ced [**2-5**] to pos UA, but reinserted overnight [**12-20**] [**2-5**] no
urine.
- continue foley
- restarted flomax [**12-27**]; currently unable to transfer to
urinal. should d/c foley for trial after pt. increases mobility
to maximize chance for success.
.
.
# Code: full, long discussions were held with patient. Patient
is considering DNR/DNI status and discussion should be
continued.
.
# FEN: soft diet with ensure, patient was given megace and
mirtazapine for appetite stimulation with good effect
Discharged to rehab for more intensive physical therapy [**2-5**]
deconditioning after long hospital stay
Medications on Admission:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4H (every 4 hours) as needed.
5. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
nebulizer Inhalation Q4H (every 4 hours) as needed.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
10. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
16. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
19. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO
BID (2 times a day).
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift. .
21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
22. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
23. Insulin
Pt receives NPH 12 units at breakfast, 9 units at bedtime, plus
fingersticks qid and a sliding scale for coverage
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours for as directed days: 125mg po tid for 3 days, then
125 mg po bid for 5 days, then 125mg po qday for 5 days then
off.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
6. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) [**3-8**] ML
Miscellaneous Q6H (every 6 hours) as needed for break up
secretions.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) 10 ml PO BID
(2 times a day) as needed for constipation.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
11. Insulin Lispro 100 unit/mL Solution Sig: as dir
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): sub cutaneous injection.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
14. Megestrol 40 mg/mL Suspension Sig: Four Hundred (400) mg PO
BID (2 times a day).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
17. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed.
18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for diarrhea.
21. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
22. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
23. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
24. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
25. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
26. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold if SBP<90.
27. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
28. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
29. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime: adjust per finger sticks.
30. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Country [**Hospital 731**] Rehabilitation & Nursing Center - [**Location (un) 5028**]
Discharge Diagnosis:
Primary diagnosis:
C. diff. colitis
Acute on chronic systolic CHF
STEMI
[**Hospital 7792**]
[**Hospital **]
Hospital acquired pneumonia and sepsis
Ischemic optic neuropathy
s/p drug-eluting stent placement
.
Secondary diagnoses:
PVD- s/p aorto [**Hospital1 **] fem bypass
DM, on insulin
COPD
Mesenteric ischemia s/p stenting of SMA
Discharge Condition:
good, tolerating pos, minimal diarrhea, satting well on RA, able
to sit for 1-2 hours with assist
Discharge Instructions:
You have came into the hospital with a bowel infection. You
have had a complicated course, developed a pneumonia and were in
the ICU for several days for treatment of your infections. The
pneumonia has been treated, but the bowel infection requires
continued antibiotics. You are to continue the PO vancomycin on
taper as directed with your medications.
While in the Emergency department you suffered from a cardiac
arrest and required a shock. You also have had multiple heart
attacks, one of which required catheterization with balloon
stenting of the blocked area.
Please call your primary care doctor or return to the hospital
if you have chest pain, shortness of breath, [**Hospital1 **] >101.4, or
any new symptoms which are concerning to you.
Please continue with your medications as instructed.
Please attend all follow up appointments below.
Followup Instructions:
Please follow up at the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2179-2-10**] 3:40
Please follow-up in Tuesday [**Hospital1 18**] Plastic Surgery
Hand Clinic after discharge. You can make an appointment by
calling: [**Telephone/Fax (1) 4652**]
Additionally, please follow up with neuroophthamology. The
number is [**Telephone/Fax (1) 24169**]. They have been notified and should call
you to make an appointment, but please call to arrange
appointment
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
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2,974
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29124
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Discharge summary
|
report
|
Admission Date: [**2171-3-27**] Discharge Date: [**2171-4-10**]
Date of Birth: [**2115-6-10**] Sex: M
Service: MEDICINE
Allergies:
vancomycin / Unasyn
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
S/P Arrest
Major Surgical or Invasive Procedure:
[**2171-3-27**] endotracheal intubation
[**2171-3-27**] PICC line placement
History of Present Illness:
53M with recent intoxication who presented s/p fall with 30
minutes of PEA arrest of unclear etiology.
.
Reportedly, patient fell down 4 stairs and his neck became
wedged face down between iron raling and fence pole. He was
lifted over this. On arrival patient was noted to be weithout
pulse and in PEA arrest. PIV access was obtained, ETT tube was
inserted with visualization of cords. Pupils were noted to be
pinpoint and 2mg narcan was admistered. Pt was without pulse for
30 minutes before spontaneous regain of circulation (without
ACLS medications). CPR was discontinued.
En route, patient continued to be unresponsive. He was given 2
PIV,Narcan withotu improvement of MS. On arrival to OSH,
patient was in SR, BP 139/85, HR 87, 96% ventilator.
On arrival to the OSH, patient was intubated, completely
unresponsive and flaccid with no reflexes in lower extremities.
He was started on sedation with versed and fentanyl,which were
the only medications he received prior to transfer to the MICU.
He was started on hypothermic protocol. He was med flighted
here but was unable to continue therapeutic hypothermia on
transfer.
On arrival to [**Hospital1 18**], patient was evaluated with CT head,neck and
torso. Trauma evaluation included imaging of head, neck, and
torso.
Imaging of his head neck and torso were unrevealing. [**Month (only) 116**] have
broken his nose a bit.
Upon return from CT resumed on hypothermic protocol, T 33.5C.
ETOH level of 292. Pt was bolused fentanyl and vecuronium. In
the ED he was biting down on the tube, but rest of his body was
paralyzed. Was started on propofol which relaxed pt. HR and BP
have been within normal limits. FAST echocardiography showed
globably working heart but not a great pump. C collar is stll
on, unable to remove given lack of mental status.
.
On arrival to the MICU, pt was intubated, unarousable. Family
unable to be contact[**Name (NI) **].
Review of systems:
unable to obtain.
Past Medical History:
Alcohol Abuse
Prior tracheostomy in [**2165**] for a retropharyngeal abscess
asthma
Social History:
Per family does abuse alcohol, with worsening recent intake due
to his mother's death. Has three daughters and is from [**Name (NI) 29158**]. Prior landscaper but hasn't worked in years due to
back pain and alcohol
Family History:
brother with bipolar, alcoholism in many family members,
schizophrenia in sister who committed suicide (~2 years ago) and
also mental health problems in mother (paranoia, aggression but
no diagnosis made) who died 2 weeks prior to admission
Physical Exam:
ADMISSION PHYSICAL EXAM:
vitals unknown (not previously recorded)
General: intubated, sedated, pinpoint pupils, nonresponsive
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, distended, nontender. act bowel sounds present,
no organomegaly
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: not responsive, no withdrawl to pain, pupils non
responsive, Babinski equivocal, no twitchings, no clonus.
.
DISCHARGE PHYSICAL EXAM:
Tmax 99.7, BP 120-135/76-85, HR 88-106, RR 8, saturation >95% RA
GENERAL - alert and interactive though easily distractible
HEENT - sclerae anicteric, MMM
NECK - Supple, no thyromegaly, JVP difficult to assess
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no wheezes/rales/ronchi, with upper airway lung
sounds
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, PICC line on
right c/d/i
SKIN - no rashes or lesions
NEURO: [**Last Name (un) 664**] affect, arousable, oriented to person, uses
objects in the room to try to figure out the date and location,
muscle strength 5/5 in bilateral upper extremities, unable to
ambulate/very ataxic gait, cerebellar exam impaired, cranial
nerve exam nonfocal although patient was so distractible that it
was difficult to assess fully
Pertinent Results:
ADMISSION LABS:
[**2171-3-26**] 10:36PM BLOOD WBC-8.0 RBC-4.62 Hgb-14.2 Hct-42.7 MCV-92
MCH-30.7 MCHC-33.2 RDW-14.1 Plt Ct-176
[**2171-3-27**] 03:07AM BLOOD Neuts-82.0* Bands-0 Lymphs-14.7*
Monos-2.6 Eos-0.1 Baso-0.5
[**2171-3-26**] 10:36PM BLOOD PT-11.4 PTT-27.3 INR(PT)-1.1
[**2171-3-27**] 03:07AM BLOOD Glucose-133* UreaN-12 Creat-0.8 Na-135
K-3.7 Cl-99 HCO3-17* AnGap-23*
[**2171-3-27**] 03:07AM BLOOD ALT-64* AST-91* CK(CPK)-257 AlkPhos-48
TotBili-0.4
[**2171-3-27**] 03:07AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.8
[**2171-3-26**] 10:47PM BLOOD pH-7.25* Comment-GREEN TOP
[**2171-3-26**] 10:47PM BLOOD freeCa-1.02*
[**2171-3-26**] 10:47PM BLOOD Glucose-137* Lactate-3.3* Na-138 K-3.5
Cl-103 calHCO3-19*
.
CT HEAD NECK [**3-26**]:
FINDINGS: The patient is intubated with the tip of the
ventilation tube above
the carina. The orogastric tube is coiled within the oropharynx
and does not
reach to the stomach.
.
CT HEAD: The cerebral sulci, ventricles, and extra-axial
CSF-containing
spaces have normal size and configuration. There is no shift of
the midline
structures. The [**Doctor Last Name 352**]-white matter differentiation of the brain
parenchyma is
well preserved, and there is no CT evidence of intracranial
hemorrhage or
acute ischemic infarct.
No fractures are identified. Mucosal thickening is involving the
bilateral
ethmoid and right maxillary sinus.
.
CTA HEAD: The intracranial internal carotid, vertebrobasilar and
anterior,
middle and posterior cerebral arteries are patent with normal
contrast
enhancement and branching pattern. There is no evidence of
stenosis,
occlusion, aneurysm, or arteriovenous malformation.
.
CTA OF THE NECK: The origins of the common carotid and vertebral
arteries are
patent without significant stenosis. The common, internal and
external
carotid arteries are normal in appearance. There is no evidence
of
hemodynamically significant stenosis or dissection. The cervical
portions of
the vertebral arteries likewise demonstrate normal contrast
opacification.
Note is made of atelectasis involving the bilateral lung apices.
IMPRESSION:
1. Normal CT of the head, specifically without evidence of
post-traumatic
hemorrhage or skull fracture.
2. Normal CTA of the head and neck.
3. Incidental note of coiled orogastric tube in the oro- and
hypopharynx.
Repositioning is recommended
.
TTE [**3-27**]:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is borderline pulmonary artery systolic hypertension.
There is a prominent anterior fat pad with a very small
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function.
.
CT HEAD [**3-30**]:
1. No acute intracranial pathology. A small hypodense focus in
the right
internal capsule- uncertain chronicity. If there is concern for
acute
infarction, an MRI can be performed if not CI.
2. Pansinus opacification ?(likely relates to the endotracheal
intubation).
The study and the report were reviewed by the staff radiologist.
.
CXR [**3-31**]:
1. Change in position of PICC line, which may be accentuated by
lordotic
positioning. The tip now overlies the upper right atrium.
2. Left lower lobe collapse and/or consolidation, unchanged.
3. Prominence of the cardiomediastinal silhouette and vascular
markings, also
grossly unchanged.
.
[**2171-4-4**] CXR PA/LAT: FINDINGS: As compared to the previous
radiograph, there is no relevant
change. No endotracheal tube. Borderline size of the cardiac
silhouette
without pulmonary edema. No pleural effusions. No evidence of
pneumonia.
Right-sided PICC line in constant position.
.
[**2171-4-4**] MRI HEAD:
FINDINGS: There is no acute intracranial hemorrhage, infarction,
edema, mass
or mass effect seen. The ventricles and sulci appear age
appropriate. No
diffusion abnormalities are seen. There is no signal abnormality
on the
gradient echo images. A small focus of T2 FLAIR hyperintensity
seen in the
right internal capsule extending into the corona radiata likely
represents an
old infarct. Major intracranial flow voids are preserved. There
is mild
mucosal thickening in the maxillary, ethmoid and sphenoid
sinuses as seen on
the earlier CT studies.
IMPRESSION: No acute intracranial abnormality.
Brief Hospital Course:
Mr. [**Known lastname **] is a 53 year old male with alcohol abuse who was
admitted after a reported pulseless arrest for 30 minutes in the
field before return of circulation. He was originally
transferred from outside hospital with an endotracheal tube to
undergo the Arctic Sun cooling protocol. He completed this but
the only cause for his arrest that could be found was
intoxication and possible resultant hypoxia (cardiac work-up
negative). He was treated for aspiration pneumonia with
levofloxacin x 8 days when he developed a fever and cough with
MSSA in the sputum. Unfortunately, he continued to have altered
mental status after completion of antibiotics and resolution of
acute cardiopulmonary issues. The altered mental status was
determined to be anoxic brain injury.
.
# Status post PEA arrest: Per the EMS report, his PEA arrest was
in the setting of being intoxicated and falling from his porch,
with his head and neck becoming stuck in the fence of his front
yard. His friends and family who witnessed this said that he
had already turned blue before EMS arrived and that everyone had
a very difficult time extracting him from the fence/porch.
Based on history, report of 30 minutes of CPR, no strips from
the event were sent with the patient and he never received any
ACLS medications per the documentation. On arrival he was
started on the therapeutic hypothermia protocol for neurologic
protection. He was cooled to 32 degrees celsius for about 16
hours and rewarmed early, as he had no evidence of renal or
hepatic dysfunction, negative cardiac enzymes and his
echocardiogram did not have any evidence of systolic or
diastolic dysfunction, which made a primary arrest event
unlikely. He was monitored on continuous EEG monitoring for
over 24 hours with no evidence of seizure after rewarming and
decreasing his sedation. He was started on aspirin 81 mg daily
and continued on his home simvastatin 40 mg daily for ongoing
CAD and stroke risk modification.
.
# Respiratory failure: patient was initially intubated by EMS in
the setting of a possible arrest, and initially had a P:F ratio
that suggested acute lung injury, thought to be due to an
aspiration event. His oxygenation improved over the next few
days, but he spiked a fever and his sputum production increased
along with a worsening left basilar consolidation concerning for
pneumonia. His sputum culture grew out Staph aureus which
speciated out to MSSA. He completed an 8 day course of
levofloxacin for pneumonia. His mental status remained the
biggest barrier to extubation, as he would become very agitated
off sedation, so he was tried on precedex and prn haldol for
agititation and his mental status became less agitated. He was
eventually extubated and performed well off the vent. He does
have significant neck thickness and snores when sleeping, has
never had sleep apnea work-up.
.
# Anoxic brain injury: When he was finally weaned off sedation
and mechanical ventilation, he had altered mental status. He
was manifesting symptoms of impaired attention/concentration and
was hyperarousable on exam. Per his family, this was a very big
change from baseline mental status. His normal personality is a
"big jokester," "flirt," and very lighthearted with a good
memory. He underwent an MRI which was negative for acute focal
damage and his labs did not show evidence of electrolyte
abnormalities, toxicities (besides alcohol), or infection. His
TSH and B12 were normal. Neurology was consulted and they felt
that his symptoms were most consistent with axonal injury due to
the fall and anoxic brain injury. It was too early during this
hospitalization to determine how much recovery he may have. His
family was given the contact information for Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] who is a traumatic brain injury and frontal lobe
disinhibition specialist. His mental status on discharge was
lethargic but arousable, easily distractible, only oriented to
person. He was working with occupational and physical therapy
to help adapt to his new baseline.
.
# Rash: pt noted to have diffuse morbilliform rash on trunk,
extremities, and face. This occured in the setting of receiving
cefepime empirically for fevers (see below) and having a past
history of penicillin allergy. The cefepime was changed in
favor of levofloxacin which MSSA was susceptible to. His rash
resolved after about 3-4 days.
.
# Aspiration pneumonia: Pt spiked fevers to 101 over the day of
[**3-28**]. Blood, urine, sputum all sent for culture and sputum grew
out Staph aureus (MSSA) as well as GNR. Concern for
ventilator-associated pneumonia vs. sinusitis given the
opacifications of his sinuses on CT. He was started on
vanc/cefepime empirically until the MSSA speciated. It was
susceptible to levofloxacin so he was changed to monocoverage to
complete an 8 day course. Also continued his albuterol HFA and
fluticasone inhaler [**Hospital1 **] for reactive airway disease.
.
# Alcohol intoxication: he had a high level on admission (> 200)
and per the family has a significant history of alcohol abuse.
He was initially on propofol which would help treat withdrawal,
then was managed with ativan for agitation due to concern about
alcohol withdrawal. After he had been in the hospital for 4
days the benzodiazepines were discontinued, and he was
transitioned to prn haldol for agitation. He did not require
any medications for agitation for several days before discharge.
.
# Cervical spine trauma: CTA of his neck on admission had no
evidence of fracture but he was maintained in a cervical collar
until he was able to wake up to confirm whether or not he had
any pain on examination. His cervical spine was cleared after
extubation.
.
# Transaminitis: very mild on admission and trended down over
the next 24-48 hours, hepatitis B and C serologies were negative
and it thought to be due to his alcohol abuse.
.
TRANSITIONAL ISSUES:
- Please assist with alcohol/substance abuse counseling and
detox
- Consider work-up for obstructive sleep apnea and setting up
CPAP. This might help with his lethargy during the day time and
his asthma symptoms
- Please assist with physical therapy and occupational therapy
Medications on Admission:
albuterol HFA
furosemide 20 mg daily
tramadol 50 mg prn
loratidine 10 mg daily
fluticasone 110mcg IH [**Hospital1 **]
simvastatin 40 mg daily
metoprolol succinate 25 mg daily
aspirin prn?
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
Wheezing.
2. loratadine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
3. fluticasone 110 mcg/actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr [**Hospital1 **]:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. folic acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
8. multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever. Tablet(s)
10. polyethylene glycol 3350 17 gram Powder in Packet [**Hospital1 **]: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
11. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab
Discharge Diagnosis:
PRIMARY DIAGNOSIS
cardiac arrest due to pulseless electrical activity/hypoxia
anoxic brain injury
alcohol intoxication and fall
aspiration pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital because the EMS team found you
unresponsive and only barely breathing. There was concern that
your heart had stopped or you had stopped breathing so a tube
was inserted into your lungs to help breathe for you and your
body was cooled to try to preserve your brain function.
Unfortunately, when you woke up, you were still confused and
showed signs of brain injury. This is most likely because your
brain was not getting enough oxygen while you were getting CPR.
This is also affecting your ability to walk independently so you
were sent to rehab to work on your balance again.
The following changes were made to your medications:
- Please START taking thiamine and folate supplements.
- Please take a multivitamin daily
- Please take acetaminophen for pain
- You may use Miralax as needed for constipation.
- Please START taking aspirin 81 mg daily for stroke prevention
- STOP taking furosemide
It is very important that you keep all of the follow-up
appointments listed below. You should bring all of your
medications to each appointment so your doctors [**Name5 (PTitle) **] update their
records and adjust doses as needed. Also, your family members
should call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who is a neurologist that
specializes in traumatic brain injuries.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 1703**] to make an
appointment in the next 2 weeks. He specializes in traumatic
brain injuries.
While you are at rehab, the doctors at the facility will care
for you. When you are ready to leave, they will help make
appointments with your primary care doctor for outpatient
follow-up. Primary care doctor: Name: [**Last Name (LF) 1955**],[**First Name3 (LF) **]
Location: [**University/College **] PRIMARY MEDICINE, LLC
Address: [**Street Address(2) 70105**], [**Location **],[**Numeric Identifier 21478**]
Phone: [**Telephone/Fax (1) 70106**]
Fax: [**Telephone/Fax (1) 70107**]
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23,675
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54615
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Discharge summary
|
report
|
Admission Date: [**2142-6-10**] Discharge Date: [**2142-6-21**]
Date of Birth: [**2093-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Trilafon
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
49M with h/o of CAD who has new chest pain and SOB.
Major Surgical or Invasive Procedure:
Cardiac Catheterization
[**2142-6-15**] CABG x 4 (LIMA-LAD, SVG- > D1, D2, PDA)
History of Present Illness:
This is a 49 year old gentleman with a history of bipolar
disease, DM II, CAD s/p MI and stent x 2 in [**2139-1-24**] who
presents with chest pain and shortness of breath. The patient
does not wish to give a history at this time but in the ED he
describes the pain as being in the center of his chest and
"feels like an elephant on his chest." This pain has been
worsening for the past six days and is associated with decreased
exercise tolerance.
In the ED he received 3 tablets of nitroglycerine, metoprolol 25
mg, aspirin 325 mg, plavix 75 mg and was started on heparin and
integrillin gtt (w/initial integrillin bolus). Cardiac enzymes
were significant for a troponin of 0.4.
On limited ROS, he currently denies fevers, chills, chest pain,
shortness of breath, nausea, vomiting or abdominal pain.
Past Medical History:
1. Bipolar disorder - housed at [**Hospital1 **] House, history of
psychotic mania
2. Insulin-dependent diabetes mellitus.
3. Coronary artery disease, status post MI and stent times
two in [**2139-1-24**].
4. Hypertension.
5. Hypercholesterolemia.
6. ALL treated in [**2123**] by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
7. Epistaxis s/p spheno-palantine artery embolization [**2138**]
Social History:
Per the patient he lives in an apartment but someone is trying
to take his home away. The patient is a two pack per day
smoker. No ethanol use. No IV drug use. Occupation: says he
"works all day emailing, talking to people, used to play
baseball"
Family History:
unknown
Physical Exam:
Vitals: T: 97.8 BP: 126/83 P: 72 R: 18 O2: 100% on RA
General: Well nourished, in no acute distress
HEENT: PERRL, EOMI, sclera anicteric, no LAD
Neck: supple
Lungs: Clear to auscultation, no wheezes, rales or ronchi
CV: Regular rate and rhythm, nl s1 + s2, no murmurs/rubs/gallops
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no clubbing/cyanosis/edema
Psych: flat affect
Pertinent Results:
[**2142-6-20**] 12:45PM BLOOD WBC-6.6 RBC-3.11* Hgb-8.4* Hct-24.6*
MCV-79* MCH-27.0 MCHC-34.0 RDW-17.9* Plt Ct-256#
[**2142-6-20**] 12:45PM BLOOD PT-12.2 PTT-22.1 INR(PT)-1.0
[**2142-6-20**] 12:45PM BLOOD Glucose-158* UreaN-22* Creat-1.3* Na-139
K-4.3 Cl-98 HCO3-31 AnGap-14
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2142-6-20**] 7:51 AM
CHEST (PA & LAT)
Reason: s/p CABG w/SOB-r/o effusion/PTX
[**Hospital 93**] MEDICAL CONDITION:
49 year old man s/p CABG
REASON FOR THIS EXAMINATION:
s/p CABG w/SOB-r/o effusion/PTX
REASON FOR THE STUDY: Assessment for effusion and pneumothorax
in a patient status post CABG with shortness of breath.
TECHNIQUE: PA and lateral view of the chest.
COMPARISON: Available for this study from [**2142-6-19**].
FINDINGS: There is improved left apical pneumothorax best
visualized on lateral views. There is a stable left pleural
effusion. Heart, mediastinal and hilar contours are normal.
Lungs are clear.
Impression: Improving small left apical pneumothorax. Stable
left pleural effusion.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Cardiology Report ECHO Study Date of [**2142-6-15**]
PATIENT/TEST INFORMATION:
Indication: Intraoperative TEE for CABG procedure
Height: (in) 72
Weight (lb): 180
BSA (m2): 2.04 m2
BP (mm Hg): 134/78
HR (bpm): 65
Status: Inpatient
Date/Time: [**2142-6-15**] at 10:51
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.8 cm
Left Ventricle - Fractional Shortening: 0.32 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 0.8 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]
LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Mild symmetric LVH. Normal LV cavity size. Mild-moderate
regional LV
systolic dysfunction. No resting LVOT gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
hypo; mid anteroseptal - hypo; mid inferoseptal - hypo; mid
inferior - hypo;
septal apex - hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no
atherosclerotic plaque.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
Conclusions:
Prebypass
1.No spontaneous echo contrast or thrombus is seen in the body
of the left
atrium or left atrial appendage. No atrial septal defect is seen
by 2D or
color Doppler.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. There is mild to moderate regional left
ventricular
systolic dysfunction. Resting regional wall motion abnormalities
include
mildly depressed mid portion of the inferior wall, inferior
septum and
anteroseptal walls.
3. Right ventricular chamber size and free wall motion are
normal.
4.The ascending, transverse and descending thoracic aorta are
normal in
diameter and free of atherosclerotic plaque.
5.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion and no aortic regurgitation.
6.The mitral valve appears structurally normal with trivial
mitral
regurgitation.
7.There is no pericardial effusion.
Post Bypass
Patient is AV paced and is receiving an infusion of
phenylephrine.
1. Biventricular systolic function is unchanged.
2. Aorta intact post decannulation.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2142-6-15**] 16:00.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 111715**])
Brief Hospital Course:
This 49M presented to the ED on [**2142-6-10**] with CP and was admitted
with acute coronary syndrome. His troponin was 0.4 and he was
started on a heparin and integrillin. He was seen by psychiatry
regarding competency and they felt he could consent to
procedures. He underwent cardiac cath on [**6-11**] which revealed:
30-40%LMCA stenosis, 40% proximal in-stent restenosis of LAD
with a mid 70-80% stenoses and a subtotally occluded mid-distal
LAD lesion, 70-80% LCX, and a patent stent in the RCA with a 50%
distal RCA. An echo revealed a 40-45% LVEF and cardiac surgery
was consulted.
On [**6-15**] the patient had a CABGx4(LIMA->LAD, SVG->Diag1, diag2,
and PDA. The cross clamp time was 82 mins., total bypass time
93 mins. The pt. tolerated the procedure well and was
transferred to the CSRU in on Neo and Propofol in stable
condition. He was extubated on the post op night and was
transferred to the floor on POD#1. His chest tubes were d/c'd
on POD#1 and his epicardial pacing wires were d/c'd on POD#3.
He was followed by psychiatry who adjusted his meds. He also had
elevated blood sugars and [**Last Name (un) **] was consulted. He was started
on glyburide, metformin, and lantus. He continued to improve
and was discharged to home on POD#6.
Medications on Admission:
Aspirin 325 mg p.o.
Lopressor 25 mg p.o. [**Hospital1 **]
Depakote 1,000 mg p.o. [**Hospital1 **].
Risperdal 2 mg in PM, 1 mg in AM
Abilify 15 mg p.o. daily
Gemfibrozil 600 mg p.o. [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Risperidone 1 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Aripiprazole 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
13. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
15. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
17. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
18. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime.
Disp:*1 3* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
bipolar
DM2
CAD s/p MI & stent x 2 ([**2138**])
HTN
lipids
ALL s/p BMT [**2123**]
T&A
spheno-palatine artery embolization for epistaxis [**2138**]
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No heavy lifting or driving.
Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] (new cardiologist) ([**Telephone/Fax (1) 1987**] 2 weeks
Dr. [**Last Name (STitle) 74756**] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-6-21**]
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"V15.3",
"272.0",
"414.01",
"V42.82",
"410.71",
"512.1",
"412",
"V10.61",
"296.80",
"305.1",
"250.00",
"V45.82",
"401.9",
"996.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"99.04",
"36.15",
"89.60",
"37.22",
"39.61",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
10859, 10917
|
7237, 8501
|
340, 422
|
11112, 11120
|
2411, 2820
|
11377, 11711
|
1970, 1979
|
8750, 10836
|
2857, 2882
|
10938, 11091
|
8527, 8727
|
11144, 11354
|
3686, 7137
|
1994, 2392
|
249, 302
|
2911, 3660
|
450, 1256
|
7171, 7214
|
1278, 1688
|
1704, 1954
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,500
| 198,384
|
39068
|
Discharge summary
|
report
|
Admission Date: [**2175-6-2**] Discharge Date: [**2175-6-8**]
Service: MEDICINE
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 13685**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 86608**] is a [**Age over 90 **]M with a history of CAD, CHF (LVEF 20%),
atrial fibrillation, moderate atrial stenosis, chronic renal
insufficiency (creatinine 1.4 at baseline) transferred from
[**Hospital1 112**]/[**Hospital1 882**] on [**2175-6-3**] for further management of systolic heart
failure, pulmonary edema, and atrial fibrillation
.
The patient was admitted to [**Hospital 882**] Hospital in early [**Month (only) 116**] for
respiratory distress with flash pulmonary edema requiring
intubation, atrial fibrillation with RVR, and hypotension
requiring vasopressors. He was eventually discharged to rehab
where he spent two days and then re-presented to [**Hospital 882**]
Hospital on [**2175-5-27**] with BRBPR on tissue after wiping, low grade
fever, and leukocytosis. He was found to be C. difficile
positive and was started on PO Flagyl with PO vancomycin added
on [**2175-6-1**]. He had a tenuous hemodynamic status during the
course of his hospitalization with episodes of flash pulmonary
edema requiring BiBAP (occurring both in setting of AF w/ RVR as
well as when rate controlled)with good resopnse to small IV
lasix boluses and on maintenance lasix 20po [**Hospital1 **]. He had several
episodes of asymptomatic hypotension with systolics in the
70s-80s for which he was given small fluid boluses. For the
atrial fibrillation he was continued on his home regimen of
coreg and amiodarone (recently started on [**5-18**]) with two
episodes of RVR that responded to diltiazem 10mg IV. Coumadin
was held in setting of supratherapeutic INR of 4.3. Per OSH D/C
summary, there was concern that cardiac ischemia was
contributing to decompensated heart failure so he was
transferred to [**Hospital1 18**] for stress testing and possible cath.
.
He was transferred on [**2175-6-3**] to [**Hospital1 18**]. He had an episode of
hypotension earlier in the day so given IVF, carvedilol dose
reduced, lasix held. Then around 21:00 atrial fibrillation with
RVR. Then at 23:00 triggered for tachypnic to 40s, answering
questions but retractions on exam, evidence of pulmonary edema
on CXR. ABG at time of transfer: 7.32/39/89. Given lasix 20IV
x2, transferred to CCU.
.
On the floor, patient does not report chest pain. Per son, the
patient told friend that has not been feeling well for past 6
months with fatigue, shortness of breath.
Past Medical History:
1. CARDIAC RISK FACTORS:
- Dyslipidemia
- History of Hypertension
2. CARDIAC HISTORY:
- systolic heart failure (LVEF 20%)
- Coronary artery disease
- Atrial fibrillation on coumadin
- moderate aortic stenosis ([**Location (un) 109**] 1.1 on echo [**2175-6-3**])
- moderate to severe mitral regurgitation (3+ on echo [**2175-6-3**])
3. OTHER PAST MEDICAL HISTORY:
- Peripheral Vascular disease
- Chronic renal insufficiency (present creatinine 1.8)
- H/o recent gastrointestinal bleed
- Peptic ulcer disease
- Benign prostatic hypertrophy
- Glaucoma
- Restless legs syndrome
- Vitamin D deficiency
- Osteoporosis
- Dupuytren contracture
- Cholecystectomy
Social History:
-Lives independently at house [**Location (un) 6409**] w/ VNA
-Regular visits from only son [**Name (NI) 382**] and grandson
-Widowed for past 17 years
-Tobacco history: lifelong non-smoker
-ETOH: No-ETOH
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: Afebrile, 104/76 105 44 100%10L face tent
GENERAL: Tachypnic male sitting up in bed holding BiPAP
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: JVP not clear on exam, supple
CARDIAC:S1,S2 Irregular,II/VI systolic murmur RUSB, radiate
carotids
LUNGS: Resp labored, accessory muscle use. Crackles [**1-8**] lung
fields
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace LE edema, cool extremities
SKIN: erythematous rash on coccyx, buttocks, ecchymosis
bilateral UE
NEURO: oriented to year, self, president, MAE antigravity
Pertinent Results:
Admission labs:
[**2175-6-2**] 09:25PM BLOOD WBC-10.0 RBC-4.21* Hgb-12.4* Hct-38.6*
MCV-92 MCH-29.4 MCHC-32.0 RDW-14.1 Plt Ct-284
[**2175-6-2**] 09:25PM BLOOD Neuts-81.9* Lymphs-9.8* Monos-5.8 Eos-2.0
Baso-0.4
[**2175-6-2**] 09:25PM BLOOD PT-39.2* PTT-37.7* INR(PT)-4.1*
[**2175-6-2**] 09:25PM BLOOD Glucose-96 UreaN-33* Creat-1.8* Na-141
K-3.8 Cl-106 HCO3-26 AnGap-13
[**2175-6-2**] 09:25PM BLOOD ALT-24 AST-36 LD(LDH)-193 CK(CPK)-27*
AlkPhos-86 TotBili-0.5
[**2175-6-2**] 09:25PM BLOOD Albumin-3.4* Calcium-8.4 Phos-3.3 Mg-1.9
Iron-41*
[**2175-6-2**] 09:25PM BLOOD calTIBC-278 VitB12-410 Folate-12.1
Ferritn-118 [**2175-6-2**] 09:25PM BLOOD TSH-3.0
.
Discharge labs:
[**2175-6-8**] 06:00AM BLOOD WBC-9.6 RBC-4.31* Hgb-13.1* Hct-39.9*
MCV-93 MCH-30.4 MCHC-32.8 RDW-14.5 Plt Ct-277
[**2175-6-8**] 06:00AM BLOOD PT-17.5* PTT-25.9 INR(PT)-1.6*
[**2175-6-8**] 06:00AM BLOOD Glucose-102* UreaN-30* Creat-1.6* Na-142
K-4.2 Cl-104 HCO3-29 AnGap-13
[**2175-6-8**] 06:00AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.4
.
Portable TTE (Complete) Done [**2175-6-3**] at 1:06:08 PM
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is severe regional left ventricular systolic
dysfunction with inferior akinesis and severe hypokinesis of the
remaining segments (LVEF = 20 %). Right ventricular chamber size
is normal. with mild global free wall hypokinesis. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened. There is
moderate aortic valve stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. The mitral valve leaflets do not
fully coapt. Moderate to severe (3+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Inferior wall akinesis with remaining wall severe
hypokinesis and overall severely depressed left ventricular
systolic function. Moderate aortic stenosis. Moderate to severe
mitral regurgitation. Severe pulmonary artery systolic
hypertension.
CHEST (PA & LAT) Study Date of [**2175-6-3**] 11:26 AM
Two views of the chest demonstrate bilateral pleural effusion
with fluid
tracking along the major fissure. There is bilateral lower lobe
consolidation. The upper lung zones are relatively clear. The
heart and
mediastinum are within normal limits.
CHEST (PORTABLE AP) Study Date of [**2175-6-3**] 11:01 PM
Comparison is made to the prior study of the same day from 11:37
hours. There is cardiomegaly. The aortic arch is mildly
calcified. There is mild
congestive failure with mild bibasilar atelectasis and left
lower lobe
consolidation. There are small bilateral pleural effusions.
These findings
have not changed considerably since prior study.
Brief Hospital Course:
[**Age over 90 **]M with a history of CAD, systolic heart failure(LVEF 20%),
atrial fibrillation, moderate atrial stenosis, chronic renal
insufficiency (creatinine 1.4 at baseline) transferred to CCU
for respiratory distress with evidence of acute pulmonary edema.
.
# RESPIRATORY DISTRESS: Most likely acute pulmonary edema in the
setting of atrial fibrillation with rapid ventricular rate in a
patient with severe systolic heart failure and tenuous fluid
status. CXR not consistent with pneumonia. Pulmonary embolism
unlikely given given supratherapeutic INR. Patient was diuresed
with iv lasix and respiratory status improved. Patient
transitioned to increased dose of PO lasix on discharge. Weight
on discharge 71.5kg close to dry weight.
.
# HYPOTENSION: The suspicion is highest that intermittent
hypotension is due to reduced cardiac output in setting of acute
on chronic systolic heart failure. Patient's SBP stabalized
during diuresis. Currently maintaining SBP >80, hemodynamically
stable. Patient's carvedilol was restarted at a reduced dose but
his lisinopril was not given his history of low blood pressure.
- Please do not give ivfs for low blood pressure, unless patient
is symptomatic
- Tolerates SBP of 80s
.
# SYSTOLIC HEART FAILURE: Patient with EF of 20% on most recent
echo thought to be [**2-7**] ischemic heart disease. As stated
patient's was diuresed. His carvedilol was restarted but his
lisinopril was held [**2-7**] low blood pressures. Patient's was
euvolemic on PO lasix prior to discharge.
.
# ATRIAL FIBRILLATION: Currently in atrial fibrillation with
ventricular rate in 80-90s. Patient was started on amiodarone at
the OSH and this was continued while at [**Hospital1 18**]. His coumadin was
held because it was supratherapeutic on admission. Given that it
then became sub-therapeutic, cardioverson was not pursued this
admission. Patient will continue on his home dose coumadin of
3mg and have cardioversion as an outpatient. Patient is also on
carvedilol.
.
#HISTORY OF CORONARY ARTERY DISEASE: Unclear history, TTE with
evidence of inferior wall akinesis possible c/w old infarct.
Patient is to continue on aspirin, atorvostatin, and carvedilol.
Ace-inhibitor may be restarted as outpatient if blood pressure
improves.
.
# C. DIFFICILE ASSOCIATED DISEASE: Patient treated initially
with IV flagyl and vancomycin. Currently, patient on po flagyl,
last dose to be on [**2175-6-11**]. On discharge patient still having
diarrhea, can consider cholestyramine at rehab if diarrhea
persists.
.
# CHRONIC RENAL INSUFFICIENCY: Baseline creatinine of 1.8, and
current Cr is below (1.6) baseline after diuresis.
.
# BRIGHT RED BLOOD PER RECTUM: No evidence of ongoing bleeding,
stable hematocrit. Assumed to be [**2-7**] hemorrhoid, no colonoscopy.
.
# TINEA CRURIS: Secondary to diarrhea, in the groin area.
Treated with nystatin cream
.
# Goals of care - family meeting was held on [**2175-6-4**]. Patient
was made DNR/DNI. Decision was made not to pursue pressors,
invasive ventilation, or BiPap. Lasix and morphine are still
acceptable. However at 17:30 on [**2175-6-8**] patient's son changed the
code status back to full code. Son would like to discuss goals
of care more with PCP before final decision is made. This change
was documented on discharge paperwork and [**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **] was
called and updated of this change.
.
#. Bruise on left great toe: noted at [**Hospital1 882**] on [**5-28**], no
evidence of infection. Can follow up with his outpatient
podiatrist.
#. Incidental lung nodule on CT at [**Hospital1 882**], needs f/u in [**3-9**]
mos as an outpatient.
Medications on Admission:
- Nystatin cream
- Ammonium lactate cream (to buttocks)
- Flagyl 500 q8h
- Lasix 20 mg [**Hospital1 **]
- Vancomycin HCl 125 mg q6h po
- Coreg 9.375 mg qam
- Coreg 12.5 mg qpm
- Atorvastatin 80
- D3 1000 QAM
- ASA 81
- Amiodarone 400 [**Hospital1 **]
- APAP 650 q6h
Discharge Medications:
1. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
2. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Give on Wednesday.
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): to groin and rectal area.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 3 days.
11. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Hold SBP < 85.
14. Outpatient Lab Work
Pleae check INR, Chem7 on Saturday [**6-10**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Atrial fibrillation on Coumadin
C difficile colitis
Coronary Artery Disease
Acute on Chronic Kidney Disease
Lower GI Bleed
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You have had many episodes of congestive heart failure in the
past month. WE think that these episodes are because of your
atrial fibrillation and have continued the amiodarone to help
with heart rate and rhythm control. We considered a
cardioversion but have not because your INR is low. WE may
recommend this in the future to convert the atrial fibrillation
to a normal rhythm. You also have been treated with antibiotics
for a bowel infection that has caused a lot of diarrhea.
We have made the following changes in your medicines:
1. Stop taking the Milk of Magnesia and dulcolax suppositories
2. Start taking a multivitamin
3. Start Nystatin powder or cream to treat the rash in your
groin area
4. Start Flagyl to finish a 10 day course. Your last dose will
be on [**2175-6-11**].
5. Start amiodarone to control your heart rhythm and rate
6. Decrease your Carvedilol to 3.125mg twice daily
7. Increase lasix to 40 mg daily
Weigh yourself every morning, call Dr. [**Last Name (STitle) 19**] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 2564**], NP with Dr. [**First Name (STitle) **] [**Name (STitle) 19**] Phone: [**Telephone/Fax (1) 2258**]
Date/time: Friday [**6-16**] at 10:30am.
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) 488**] M. Phone: [**Telephone/Fax (1) 80426**] Date/time: Please keep
any scheduled appts after you get out of rehabilitation
Completed by:[**2175-6-9**]
|
[
"V58.66",
"008.45",
"584.9",
"427.31",
"458.9",
"414.01",
"428.0",
"424.1",
"455.8",
"518.89",
"V58.61",
"585.9",
"428.23",
"110.3",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12487, 12560
|
7330, 10997
|
232, 238
|
12778, 12778
|
4281, 4281
|
14048, 14488
|
3592, 3707
|
11313, 12464
|
12581, 12757
|
11023, 11290
|
12963, 14025
|
4950, 7307
|
3722, 4262
|
2745, 2996
|
185, 194
|
266, 2634
|
4297, 4934
|
12793, 12939
|
3028, 3331
|
2656, 2724
|
3347, 3576
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,379
| 123,234
|
39686
|
Discharge summary
|
report
|
Admission Date: [**2158-8-29**] Discharge Date: [**2158-9-7**]
Date of Birth: [**2092-8-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Naprosyn /
Tramadol / Statins-Hmg-Coa Reductase Inhibitors / Ioversol
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Transfer from [**Hospital 1474**] Hospital for management of hyperglycemia.
Major Surgical or Invasive Procedure:
[**2158-8-30**]: PICC placement.
History of Present Illness:
Mrs. [**Known lastname 65193**] is a 65 yo F with history of CAD, dCHF, HTN, HL, DM
II, CKD, ILD, COPD and OSA (on CPAP) who was transfered from
[**Hospital 1474**] Hospital for management of hyperglycemia. Patient was
admitted to OSH on [**2158-8-21**] with headache and "upset stomach". OSH
head CT was normal. In the OSH ED she developed L sided SSCP;
EKG revealed ST depressions in the lateral leads and TWI in the
inferior leads. Given her complicated CAD history she was
admitted and treated for ACS. She subsequently ruled out for MI
and underwent a phamacological stress test with nuclear imaging
that revealed small reversible defect of the inferior apical
wall and a TTE that showed EF 55-60% and mild-moderate AS.
Her course was complicated by dificult to control hyperglycemia
(BG up to 800s) requiring 80 [**Location 16422**]500 TID, 20 units of novolog
with meals and prn IV insulin to maintain BG in 300-400 range.
She was tranfered to [**Hospital1 18**] for management of her hyperglycemia.
Past Medical History:
DM II (for 30 years, followed by [**Last Name (un) **])
CAD
dCHF
AF/MAT
HTN
HL
s/p cardiac arrest [**1-/2158**] during lung biopsy w/residual L eye
partial blindness
CKD (per pt, [**2-21**] K and digitalis toxicity for which she required
HDx1)
ILD
COPD (2L NC at home for last 3 weeks, no daytime use prior to
that)
OSA (on CPAP always)
Hypothyroidism ([**2-21**] Grave's Disease)
Fibromyalgia
Gout
Anemia
GERD
Social History:
Lives with husband in [**Name (NI) 1475**]. Supportive sons.
- [**Name2 (NI) 1139**]: Denies
- Alcohol: Denies
- Illicits: Denies
Family History:
Mother: DM [**Name (NI) **], MI [**18**]
Father: DM [**Name (NI) **], MI [**16**]
Physical Exam:
Vitals: T: 97.5 BP: 125/76 P: 71 RR: 15 O2: 98% 2L NC
General: Obese, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, view of oropharynx obscured by
large tongue, left posterior mandibular molar eroding through
gums without significant erythema or obvious abscess
Neck: Obese, JVP could not be assessed due to habitus, no
appreciable LAD
Lungs: Bibasilar late inspiratory crackles without wheezes
CV: RRR, grade 3 early systolic murmur best at LUSB with
preserved S2 best at apex, no rubs or gallops
Abdomen: obese, non-tender to palpation, mildly distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: feet warm and well perfused, no palpable pedal pulses, 3+
pitting edema up to thighs, and arms
Skin: Large area of RLE mildly warm, non-tender, blanching
erythema centered on medial calf; lateral calf with numerous
focal, raised erythematous lesions, one with overlying scab from
prior biopsy. Mild toenail fungus
Pertinent Results:
Labs on Admission:
[**2158-8-29**] 05:08AM URINE COLOR-[**Location (un) **] APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2158-8-29**] 05:08AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG
[**2158-8-29**] 05:08AM URINE RBC->1000* WBC-81* BACTERIA-NONE
YEAST-RARE EPI-0
[**2158-8-29**] 05:08AM URINE MUCOUS-RARE
[**2158-8-29**] 03:16AM GLUCOSE-301* UREA N-64* CREAT-1.3* SODIUM-133
POTASSIUM-3.6 CHLORIDE-92* TOTAL CO2-31 ANION GAP-14
[**2158-8-29**] 03:16AM estGFR-Using this
[**2158-8-29**] 03:16AM CALCIUM-8.9 PHOSPHATE-4.0 MAGNESIUM-2.9*
[**2158-8-29**] 03:16AM WBC-11.7* RBC-3.52* HGB-8.1* HCT-25.9*
MCV-74* MCH-23.0* MCHC-31.3 RDW-21.1*
[**2158-8-29**] 03:16AM PLT COUNT-236
[**2158-8-29**] 03:16AM PT-12.9 PTT-24.0 INR(PT)-1.1
Labs on discharge:
[**2158-9-7**] 06:24AM BLOOD WBC-8.7 RBC-3.31* Hgb-7.5* Hct-24.7*
MCV-75* MCH-22.7* MCHC-30.5* RDW-22.2* Plt Ct-277
[**2158-9-7**] 06:24AM BLOOD Glucose-90 UreaN-49* Creat-1.1 Na-136
K-4.2 Cl-95* HCO3-36* AnGap-9
[**2158-9-7**] 06:24AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
Imaging:
[**2158-8-29**] CXR (portable): There is a retrocardiac opacity, that
could reflect pneumonia and/or atelectasis. There is also a
faint opacity in the right upper lobe could reflect another
focus of developing infection or atelectasis. There is mild
vascular congestion without overt pulmonary edema, sizeable
pleural effusion, pneumothorax. Lung volumes are low, causing
exaggeration of the cardiomediastinal silhouette. There is
relative prominence of the right hilum and could be related to
vascular engorgement.
[**2158-8-30**] CXR (portable): Cardiac silhouette remains enlarged.
Linear opacity in left mid lung region is consistent with
atelectasis, and small amount of pleural fluid persists in the
right minor fissure. No new areas of consolidation to suggest
the presence of pneumonia.
[**2158-9-3**] Panorex: No report provided.
Brief Hospital Course:
This is a 65 year old female with multiple medical problems who
was transferred from [**Name (NI) 1474**] Hospital for management of
hyperglycemia. While at [**Hospital1 1474**] she had a pharmacologic stress
test showing a small inferoapical reversible defect; TTE showed
EF 55-60% and mild-moderate AS. Glucose was brought under
control in the [**Hospital1 18**] ICU. Admission U/A was consistent with
UTI, and urine cultures grew cipro resistant, nitrofurantoin
sensitive E. Coli. She was transferred to the floor where she
continued her course of nitrofurantoin, was followed closely by
[**Last Name (un) **] for her diabetes, and was diuresed due to her
decompensated diastolic heart failure. She had episodes of SVT
while on the floor which became less frequent.
# Hyperglycemia: Etiology of her increased insulin requirement
remained unclear but was hypothesized to be due to an occult UTI
given her UA showing WBC. She was initially on an insulin drip
in the ICU which was subsequently converted to U-500 [**First Name8 (NamePattern2) **] [**Last Name (un) **]
recs. Her hyperglycemia remained within her baseline range,
200-300, on a sliding scale with U-500 given four times a day at
specific times similar to when she might take her insulin at
home. She was discharged on U-500 four times daily
(90/100/60/60).
# Urinary tract infection: She was initially begun on
ciprofloxacin; when sensitivities for E.coli came back resistant
to cipro on [**2158-8-31**], she was started on a 7 day course of
nitrofurantoin 100 mg [**Hospital1 **]. Her foley catheter was removed
shortly after arriving on the floor, where she completed her
antibiotic course. She was asymptomatic while on the floor.
# Decompensated dCHF: She was ruled out with troponins WNLs x
2. She was initially started on lasix 80 mg [**Hospital1 **] and metolazone
5 mg [**Hospital1 **]. In the ICU, she required PRN IV lasix to maintain 0.5
to 1L negative daily. Her SOB improved on this regimen.
Cardiology consulted, recommending more aggressive diuresis.
She was on IV lasix only upon transfer from the ICU with goal
1-2L negative daily. To meet this goal we increased her IV
lasix from 20mg [**Hospital1 **] to 40mg [**Hospital1 **] in addition to the metolazone.
By the time of her discharge she was asymptomatic from a
respiratory standpoint but still with significant peripheral
edema. She was discharged on her home dose of 80mg lasix PO BID
in addition to metolazone. On the floor, 5mg lisinopril daily
was added. She maintained a HCO3 of approximately 34 throughout
her stay, likely a contraction alkalosis secondary to aggressive
diuresis. Her baseline HCO3 is unclear.
# CAD: When the patient arrived on the ICU, she was complaining
of SOB and chest pain, for which she had multiple unchanged EKGs
from prior. Chest pressure in the AM is common for her and is
not what she considers her angina. Her home plavix was
discontinued in the ICU as there was no obvious indication for
it. The remainder of her home medications were continued.
# Supraventricular tachycardia: She had episodes of SVTs both
in the ICU and on the general medicine floor. They were narrow
complex and regular, lasting approximately 20-30 beats and
resolving without intervention. They became less frequent by
discharge with QID metoprolol and continued diuresis. Before
telemetry was discontinued, she had approximately 3-4 episodes
nightly. She was discharged on metoprolol succinate 50mg daily.
# Tooth pain. Pain in her posterior left, mandibular molar was
her chief complaint on arrival to the general medicine service.
On exam, the tooth was eroding through the gums without
significant erythema and without obvious abscess. She was
evaluated by both a dentist and oral surgeon, who recommended
extraction as an outpatient. A panorex film was taken, but not
officially read prior to discharge.
# ILD: Patient carries an outside hospital diagnosis of ILD. At
OSH, she was started empirically on 20 mg prednisone daily, with
subjective improvement in SOB. While in the ICU, her steroid
dose was decreased to 10 mg daily, with an eventual goal of
weaning her off prednisone, which has been attempted in the past
unsuccessfully. She was ultimately discharged on 10mg daily.
It may be advisable for her to discuss bisphosphonate therapy
with her PCP.
# COPD: Patient reported a longstanding nighttime requirement
of 2L, but only wearing 2L by day over the several weeks prior
to her presentation to [**Hospital 1474**] Hospital. She was able to
maintain SaO2 > 92 while in the ICU on 2L NC. On the floor she
maintained SaO2 in the upper 90s on 1L, and at least in the mid
90s on RA. Still, she became anxious when not on O2 despite our
recommendations to go without supplementation during the day.
She has all the necessary supplies at home to accommodate her O2
requirements.
# OSA. Her use of CPAP was somewhat limited by her tooth pain,
but she wore it as tolerated. She wears oxygen overnight at
home and will continue this regimen as an outpatient.
# CKD: Unclear as to baseline renal function but OSH lab data
showed Cr 1.4-1.5. Her Cr trended down throughout her admission
to a discharge Cr of 1.1.
# Constipation: She was placed on an aggressive bowel regimen.
Her presenting abdominal discomfort subsequently improved.
Medications on Admission:
Medications at home:
Ativan 0.5 mg q12 prn
Allopurinol 300 mg daily
Flonase 2 sprays to each nostril daily
Nitrostat prn
Carafate 1 g QD
Diltiazem CD 240 mg daily
Metoprolol XL 12.5 mg daily
Metolazone 5 mg [**Hospital1 **]
Lasix 80 mg daily
Prednisone 20 mg daily
ASA 325 mg daily
Ca/VitD
Lanoxin 0.125 mg daily
Albuterol neb prn
Synthroid 225 mg daily
Colchicine 0.6 mg daily
Prilosec 20 mg [**Hospital1 **]
Vicodin 5/500 q4-6 prn
Humilin U-500 40,40,60 w/ B,L,D respectively
Lispro SS
Aldactone 25 mg TID
Colace 100 mg [**Hospital1 **]
Neurontin 300 mg TID
.
Medications on transfer:
Humilin U-500 40,40,60 w/ B,L,D respectively
Acetaminophen prn
Acetylcysteine IH prn
Albuterol neb prn
Allopurinol 300 mg daily
[**Doctor Last Name **]/Mag 15 mL prn
ASA 325 mg prn
ASA-Caffeine-Butalbitial [**1-21**] tab q4 prn
Ca/Vit D
Clopidogrel 75 mg daily
Digoxin 0.125 mg daily
Synthroid 225 mg daily
Colchicine 0.6 mg daily
Diltiazem CD 240 mg daily
Docusate
Fluticasone 2 spray daily
Furosemide 80 mg [**Hospital1 **]
Gabapentin 300 mg TID
Vicodin prn
Lispro SS
Ipratopium neb q6h
Lorazepam 0.5 mg q12 prn
Metolazone 5 mg [**Hospital1 **]
Metoprolol XL 25 mg daily
Niacin 1000 mg qhs
SLN
Nystatin TID
Omeprazole 20 mg [**Hospital1 **]
Miralax daily
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for anxiety: (Ativan).
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays to each nostril Nasal once a day.
4. Nitrostat 0.4 mg Tablet, Sublingual Sig: 1-2 tablets
Sublingual every 6-8 hours as needed for chest pain.
5. Carafate 1 gram Tablet Sig: One (1) Tablet PO once a day.
6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): For best results, take 30 minutes prior to lasix.
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Take your lasix in the morning and six hours later (i.e.
7AM and 1PM) to prevent urination at night.
Disp:*60 Tablet(s)* Refills:*0*
10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Home med.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**1-21**] nebulizers Inhalation Q6H (every 6 hours)
as needed for shortness of breath or wheezing.
15. Levothyroxine 112 mcg Tablet Sig: Two (2) Tablet PO once a
day.
16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
18. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
19. Aldactone 25 mg Tablet Sig: One (1) Tablet PO three times a
day.
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
21. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
22. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
23. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
24. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
25. Tessalon Perle 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
26. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
27. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every twelve (12)
hours as needed for nausea.
Disp:*12 Tablet(s)* Refills:*0*
28. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: as
directed Injection four times a day: Take 90 units at
breakfast, 100 units at lunch, 60 units at dinner, and 60 units
at bedtime.
Disp:*QS * Refills:*0*
29. A/B Otic 5.4-1.4 % Drops Sig: Five (5) drops Otic every [**4-25**]
hours as needed for ear pain.
Disp:*QS * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary: Hyperglycemia, type II diabetes mellitus, diastolic
congestive heart failure, E. coli urinary tract infection,
supraventricular tachycardia
Secondary: Coronary artery disease, hypertension, obstructive
sleep apnea, anemia, GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Hospital 1474**] Hospital due to
uncontrollably high blood sugars. While at [**Hospital1 1474**], you had a
stress test done on your heart that showed a small area of low
blood flow; you elected not to undergo cardiac catheterization
due to your shortness of breath while lying flat. You spent
five days in the [**Hospital1 18**] ICU, where your sugars were brought under
control. You were noted to have a urinary tract infection
(UTI), which we treated with an antibiotic called
nitrofurantoin. You have spent several days on the general
medicine service, where we have continued treating your UTI and
also have taken off excess fluid using intravenous lasix. You
were monitored on telemetry for several days due to some
episodes of fast heart rate, which gradually became less
frequent. You also had some tooth pain, which was evaluated by
both a dentist and an oral surgeon; they recommended having the
tooth extracted as an outpatient. You also had some persistent
sore throat and post-nasal drip, which improved somewhat when we
started [**Doctor First Name 130**].
Please note the following medication changes:
- Please begin taking metoprolol 50mg XL rather than your prior
dose of 12.5mg.
- Please begin taking lisinopril 5mg daily
- Please increase you Lasix (furosemide) to 80mg twice daily
- Please continue to take only 10mg prednisone daily, which is
half of your admission dose
- Please adjust your home insulin U-500 dosing to 90 units at
breakfast, 100 units at lunch, 60 units at dinner, and 60 units
at bedtime as discussed with the [**Last Name (un) **] diabetes doctors.
- We have also written prescriptions for several medications you
found helpful, which you can use as needed: A/B otic drops for
ear pain, Zofran for nausea, zofran for nausea, tessalon perles
for cough, and trazadone for insomnia.
- Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 37742**], on [**2158-9-13**] at
11:30 AM. He can schedule you for a podiatry appointment and
review your medications. As prednisone can weaken your bones,
you may consider a group of medications called bisphosphanates
to maintain your bone health.
- Please follow up with your cardiologist, Dr. [**Last Name (STitle) 87464**], on
[**2158-9-19**] at 2:45PM.
Followup Instructions:
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37742**]
Location: [**Hospital **] MEDICAL GROUP
Address: [**Location (un) 87465**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 23083**]
Appt: [**9-13**] at 11:30am
*Dr. [**Last Name (STitle) 37742**] can schedule you with an outpatient podiatrist.
Cardiology: Dr. [**Last Name (STitle) 87466**] [**Name (STitle) 87464**]
Address: [**Street Address(2) 65862**], [**Hospital1 1474**]
Phone: [**Telephone/Fax (1) 87467**]
Appt: [**9-19**] at 2:45pm
|
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"427.89",
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"525.8",
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"424.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14895, 14966
|
5185, 10519
|
452, 487
|
15248, 15248
|
3208, 3213
|
17786, 18369
|
2122, 2205
|
11815, 14872
|
14987, 15227
|
10545, 10545
|
15431, 16587
|
10566, 11108
|
2220, 3189
|
16607, 17763
|
337, 414
|
4039, 5162
|
515, 1524
|
3228, 4019
|
15263, 15407
|
11133, 11792
|
1546, 1958
|
1974, 2106
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,794
| 197,068
|
14811
|
Discharge summary
|
report
|
Admission Date: [**2175-10-19**] Discharge Date: [**2175-11-7**]
Date of Birth: [**2117-9-13**] Sex: M
Service: Cardiothoracic Surgery.
HISTORY OF PRESENT ILLNESS: Briefly, this is a 58 year old
male with severe oxygen dependent chronic obstructive
pulmonary disease, chronic dyspnea on exertion, and chronic
non-productive cough, and ? EtOH abuse who recently underwent
a routine
screening CT scan and was found to have a lung mass and an
incidental 5 by 5.5 centimeters abdominal aortic aneurysm
while in the work-up of his lung mass. He had a cardiac
work-up which was positive for stress test and was stopped
for shortness of breath. The patient never complained of
chest pain or discomfort but has been severely short of
breath since [**2172**]. He wears two liters of oxygen via nasal
cannula around the clock and was intubated for pneumonia in
the past.
PAST MEDICAL HISTORY:
1. Significant for hypertension.
2. High cholesterol.
3. Chronic obstructive pulmonary disease.
4. Interstitial pulmonary fibrosis.
5. Diverticular disease.
6. Abdominal aortic aneurysm.
7. Severe arthritis.
PAST SURGICAL HISTORY:
1. Open heart surgery due to a stabbing incident.
2. Multiple fractures due to a motor vehicle accident.
3. Broken jaw due to trauma.
4. Right carotid surgery due to trauma as well.
ALLERGIES: He has no known drug allergies.
MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Hydrochlorothiazide 25 mg p.o. twice a day.
3. Norvasc 5 mg p.o. q. day.
4. Lipitor 20 mg p.o. q. day.
5. Wellbutrin 75 mg p.o. twice a day.
6. Nicotine patch.
7. Flovent two puffs q. a.m.
8. Combivent two puffs twice a day.
9. Klor-Con 20 mEq p.o. q. day.
PHYSICAL EXAMINATION: On physical examination he was
afebrile; vital signs were stable. His pupils are equal,
round and reactive to light. Extraocular muscles are intact.
He has no bruits. His neck was supple. His chest
examination had anterior and lateral scar across his sixth
intercostal space and across the sternum. His heart was
regular rate and rhythm with no murmurs, rubs or gallops. On
lung examination, he had bilateral wheezes with no crackles.
Abdomen was soft, nontender, nondistended. His extremities
were warm and well perfused with good pulses.
LABORATORY: The patient's chest x-ray showed severe
interstitial fibrosis and sub-hilar lung mass.
His white blood cell count was 8.2, hematocrit of 48,
platelets of 142. Chem-7 with sodium of 137, potassium 3.6,
chloride 96, bicarbonate 31, BUN of 13, creatinine of 1.0.
HOSPITAL COURSE: The patient was taken to the Operating
Room on [**2175-10-20**], where a coronary artery bypass graft
times three was performed, saphenous vein graft to left
anterior descending, saphenous vein graft to obtuse marginal
2, saphenous vein graft to patent ductus arteriosus. The
patient was transferred to the Cardiac Surgical Recovery Unit
postoperatively where he did well. He had a little bit of a
labile blood pressure which was treated.
He was weaned from his ventilator and extubated on
postoperative day number one and stayed on the Floor. The
patient was doing well in the Intensive Care Unit, however,
with activity his saturations would drop. He was able to
move around in bed and coughing and deep breathing. He was
continued to be watched and was transfused two units of
packed red blood cells for a low hematocrit.
On [**2175-10-23**], the patient was found to have a low pO2 on
blood gas and was placed on Bi-PAP in order to improve. The
patient continued to decline respiratory and the patient was
reintubated on [**2175-10-23**]. The patient, after reintubation
began to improve, however, was found to have significant
secretions with suctioning. A bronchoalveolar lavage was
done by Pulmonary. Pulmonary was consulted for bronchoscopy
as well as for management. It was found that he had a
pneumonia at that time.
The patient was started on Levofloxacin and Flagyl for Gram
negative rods in his sputum and given a 14 day course of
that. He was attempted to wean on his ventilator, however,
he was unable to get significant advances on his ventilator
due to desaturation with any type of activity or agitation.
At that time, it was decided that the patient was possibly
suffering from delirium tremens and Ativan was started.
Propofol was weaned off. The sputum grew out Serratia at
that time and it was found to be pan-sensitive. He was
continued on Levofloxacin and Flagyl for coverage. The
patient was also given aggressive nebulizer treatments for
his pulmonary status.
The patient began to be diuresed; tube feeds were started.
The patient was started on Haldol as well for a question of
delirium, and he was weaned from his ventilator. During that
time, repeat bronchoscopy showed clearing of his pulmonary
secretions and repeat lavage was clear. The patient, after
bronchoscopy, was extubated at that time and continued to do
well. His Foley was removed and his central line was
removed. The chest tubes were removed. The patient
continued to improve.
He was still bringing up heavy secretions, however, his
ambulatory status was more stable at this time. Haldol was
used as a standing dose as well as for p.r.n. and his Ativan
was stopped. He was transferred to the Floor on [**2175-11-3**].
He continued on Levofloxacin and Flagyl for a total of 14
days and it was stopped at that time.
Physical Therapy was consulted for ambulation and found that
the patient had been significantly deconditioned due to his
prolonged Intensive Care Unit course and felt that he would
best be served with rehabilitation placement. Aggressive
pulmonary toilet was continued on the Floor and the patient
continued to improve. One-to-one sitters were removed on
[**2175-11-5**], and the patient was screened for rehabilitation
on [**2175-11-6**].
The patient is currently awaiting rehabilitation placement.
Please see Addendum for discharge date.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. q. day.
2. Haldol 5 gm p.o. three times a day.
3. Enteric-coated aspirin 325 mg p.o. q. day.
4. Protonix 40 mg p.o. q. day.
5. Colace 100 mg p.o. q. day.
6. Nicotine 14 mg transdermal q. day.
7. Hydrocortisone Cream 0.5% apply to affected area p.r.n.
8. Bupropion 75 mg p.o. twice a day.
9. Folic acid 1 mg p.o. twice a day.
10. Thiamine 100 mg p.o. q. day.
11. Albuterol and Ipratropium one to two puffs inhalers
p.r.n.
12. Flovent two puffs inhaler twice a day.
13. Percocet one to two tablets p.o. q. four hours p.r.n.
14. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day.
DISCHARGE DIAGNOSES:
1. Severe chronic obstructive pulmonary disease with home O2
requirement.
2. Hypertension.
3. High cholesterol.
4. Coronary artery disease status post coronary artery
bypass graft times three.
5. Diverticular disease.
6. Abdominal aortic aneurysm.
7. Severe arthritis.
8. Lung mass, questionable for work-up.
9. Status post open heart surgery for stabbing.
10. Status post multiple fractures including jaw, skull,
pelvic, bilateral lower extremities.
11. Right carotid surgery due to trauma.
CONDITION ON DISCHARGE: The patient is discharged in table
condition.
DISPOSITION: To Rehabilitation facility.
DISCHARGE INSTRUCTIONS:
1. Instructed to follow-up with four weeks with Dr. [**Last Name (STitle) **].
2. To follow-up in one to two weeks with his primary care
physician ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**] and Dr. [**Last Name (STitle) 43511**].
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2175-11-5**] 15:01
T: [**2175-11-5**] 16:06
JOB#: [**Job Number **]
|
[
"291.0",
"303.90",
"414.01",
"786.6",
"411.1",
"423.1",
"998.12",
"518.5",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"88.72",
"96.72",
"37.12",
"39.61",
"37.23",
"96.05",
"36.13",
"88.56",
"88.53",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6640, 7142
|
5965, 6619
|
2562, 5942
|
7283, 7807
|
1148, 1695
|
1719, 2543
|
186, 887
|
909, 1125
|
7168, 7259
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,558
| 177,766
|
40660
|
Discharge summary
|
report
|
Admission Date: [**2110-5-8**] Discharge Date: [**2110-5-13**]
Date of Birth: [**2055-12-2**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8480**]
Chief Complaint:
Submental and mandibular periapical abscesses
Major Surgical or Invasive Procedure:
I/D Neck (submental) abscess
Removal mandibular teeth
History of Present Illness:
54 year old male with history of coronary artery disease s/p
stent and CABG, type 2 diabetes, depression, peptic ulcer
disease who presents with dental pain, submental swelling
concerning for Ludwig's angina. The patient had dental pain in
his right mandible area starting Saturday morning. He took a
long nap in the afternoon and awoke with worsened ache so he
applied orajel to the area. Of note, the patient has poor
dentition at baseline and "hate dentists." He developed swelling
Sunday, [**2110-5-4**] that progressed, with worsening pain and
subjective fevers. The pain radiated up to his ears and felt
like a deep/posterior sore throat. The swelling became firm and
enlarged by Monday and his tongue also felt swollen, making it
difficult to talk because of the pain. The patient presented
initially to [**Hospital6 3105**] on Wednesday (yesterday)
where CT maxillofacial showed a 3.5X3.2X2 cm abscess. The
patient received clindamycin and potassium repletion prior to
transfer to [**Hospital1 18**] and endorsed significant improvement in pain
and swelling afterwards. He describes mild odynophagia but no
dyspnea/orthopnea, dysphagia, trismus, stridor.
.
In the ED, VS initially T98.0, HR90, BP118/73, RR16, 100% on RA.
The patient received additional coverage with Vancomycin given
that the patient works at [**Hospital6 **] (for MRSA). Labs
drawn were stable except for borderline INR 1.2, leukocytosis to
12.8 with left shift and lactate 2.3. Blood cultures were sent.
EKG with ST depression in V2-V5 so given full dose aspirin. ENT
was consulted and performed laryngoscopy demonstrating stable
airway. OMFS was also consulted for abscess management. Panorex
performed pre-operatively and reviewed by OMFS.
.
ROS: Denies night sweats, headaches, vision changes, rhinorrhea,
cough, chest pain, abdominal pain, nausea, vomiting, diarrhea.
In particular, denies dyspnea, dysphagia, +odynophagia
.
Past Medical History:
* Coronary artery disease s/p stent in [**2101**] and CABG X3 [**2107**]
* Depression
* Peptic ulcer disease
* Type 2 diabetes mellitus
Social History:
Works at [**Hospital6 **] at the Data Center. Denies
tobacco (quit [**2108-9-20**], previously 2 ppd X 30 years); denies
illicit drugs. Rare alcohol. Happily married, second marriage.
Two children (27 yo, 32 yo) from first marriage, 18 yo and 15 yo
from this marriage.
Family History:
Father had diabetes, stroke, died of CHF at 61 years old. Mother
also died of CHF at 61 yo. Multiple aunts/uncles died of CHF.
Grandparents lived into their 90s.
Physical Exam:
VS: Temp: 97.0 BP: 133/75 HR: 92 RR: 16 O2sat 92% on RA (lying
at 30 degree angle)
GEN: Pleasant, comfortable, NAD, alert and oriented, diaphoretic
Oral: Anterior submental region tender/firm predominantly on
right side. Mild erythema or neck on right side of midline,
+warmth, +TTP. Tender area of fluctuance palpable on right. Poor
dentition, +halitosis.
No trismus. Able to open mouth gradually. Cervical
lymphadenopathy. No active purulent drainage.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no jvd
Nasal septal deviation. No stridor audible.
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Alert and oriented, cranial nerves grossly intact.
Strength and sensation grossly intact.
.
Pertinent Results:
[**2110-5-12**] 04:00PM BLOOD WBC-6.6 RBC-4.37* Hgb-13.4* Hct-37.5*
MCV-86 MCH-30.6 MCHC-35.7* RDW-13.6 Plt Ct-316
[**2110-5-8**] 05:13AM LACTATE-1.5
[**2110-5-8**] 04:49AM GLUCOSE-259* UREA N-26* CREAT-1.0 SODIUM-132*
POTASSIUM-3.2* CHLORIDE-91* TOTAL CO2-24 ANION GAP-20
[**2110-5-8**] 04:49AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.6
[**2110-5-8**] 04:49AM WBC-10.9 RBC-4.43* HGB-13.5* HCT-38.0* MCV-86
MCH-30.5 MCHC-35.6* RDW-14.0
[**2110-5-8**] 04:49AM PLT COUNT-211
[**2110-5-8**] 04:49AM PT-14.6* PTT-22.3 INR(PT)-1.3*
[**2110-5-7**] 10:35PM LACTATE-2.3*
[**2110-5-7**] 10:30PM GLUCOSE-233* UREA N-24* CREAT-1.1 SODIUM-133
POTASSIUM-3.4 CHLORIDE-90* TOTAL CO2-26 ANION GAP-20
[**2110-5-7**] 10:30PM estGFR-Using this
[**2110-5-7**] 10:30PM cTropnT-<0.01
[**2110-5-7**] 10:30PM WBC-12.8* RBC-4.76 HGB-14.6 HCT-40.6 MCV-85
MCH-30.6 MCHC-35.8* RDW-14.0
[**2110-5-7**] 10:30PM NEUTS-81.9* LYMPHS-11.6* MONOS-5.5 EOS-0.6
BASOS-0.4
[**2110-5-7**] 10:30PM PLT COUNT-227
[**2110-5-7**] 10:30PM PT-14.2* PTT-21.0* INR(PT)-1.2*
.
Panorex pending
.
Blood cultures X2 pending
.
EKG: Normal sinus rhythm, normal axis, QTc 431, moderate R wave
progression, TWI (biphasic) in V2-V4. Less pronounced on EKG
from OSH [**2108-12-21**] (TWI in V1, ?V2).
.
Imaging:
CT maxillofacial with contrast (OSH): 3.5X3.2X2cm likely abscess
in the FOM asymmetric to the right with adjacent cellulitis and
reactive lymphadenopathy. This has no clear connection to apical
tooth abscess. There is evidence of multifocal maxillary and
mandibular apical tooth abscesses. The airway remains patent.
.
Panorex: retained root tips #2,18,19,30; PARL
#2,3,6,7,10,11,14,18,19,24,28,30; carious #5-8,10,11,20,28,29;
generalized moderate periodontitis
.
WOUND CULTURE (Final [**2110-5-11**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
SPARSE GROWTH MIXED BACTERIAL FLORA ( >=3 COLONY TYPES)
CONSISTENT
WITH OROPHARYNGEAL FLORA.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Brief Hospital Course:
54 year old male with history of hypertension, hyperlipidemia,
coronary artery disease s/p stent and CABG, type 2 diabetes,
depression, peptic ulcer disease who presents with Ludwig's
angina.
.
# Ludwig's Angina: Sent to ICU for airway monitoring. Seen on CT
maxillofacial with contrast. Evaluated by ENT and OFMS. Likely
etiology is poor dentition, gingivitis and diabetes. Currently
protecting airway. Started on continue Vancomycin and
Clindamycin IV. Given decadron 10mg X1 to assist with swelling.
Planned extra-oral and intra-oral incision and drainage of
submental abscess with ENT. OFMS will try to do teeth
extractions in OR as well. Made NPO in ICU. Started peridex
mouthwash twice daily, follow-up blood cultures X2. Monitor
closely for airway; would need Trauma Surgery/ACS involved for
emergent surgical airway if decompensates. washout uneventful in
OR and all mandibular teeth extracted. See op note for details.
On floor did well post-op and transitioned to diabetic soft
diet. No further fevers and tolerated packing changes without
problem. His neck abscess cavity remained large and was packed
with iodoform gauze on a [**Hospital1 **] basis. He and his wife were
instructed in how to perform this and were insistent at the time
of discharge that she would perform the dressing changes on her
own. She was not at all interested in having a visiting nurse
help with the dressing changes. They agreed to monitor the wound
closely and call or return to the office with any concerning
changes.
.
# Coronary artery disease: s/p stent in [**2101**] and CABG X3 [**2107**].
New EKG concerning in anterior leads similar to [**2108-12-21**] [**Hospital1 2177**]
EKG. Continue metoprolol but will switch to tartrate 50mg
[**Hospital1 **],lisinopril, HCTZ,aspirin 81, atorvastatin 80mg daily.
.
# Type 2 diabetes mellitus: Possibly poor glucose control given
dental infection. On glipizide and metformin at home. Was
started on insulin sliding scale, but remained high. After d/c
of IVF and changing IV to PO antibiotics, sugars normalized and
patient was stable on home regimen. He does appear to have poor
control at baseline and will follow up with PCP regarding need
for titrating meds.
.
# Depression: Stable, continue celexa
.
# Peptic ulcer disease: Stable, continue protonix 40mg daily
Medications on Admission:
* Metoprolol succinate 100mg daily
* Lisinopril 10mg daily
* Hydrochlorothiazide 25mg daily
* Aspirin 81mg daily
* Atorvastatin 80mg daily
* Metformin 500mg twice daily
* Glipizide 5mg twice daily
* Protonix 40mg daily
* Celexa 30mg daily
* Vitamin D3 5000 units weekly
* Viagra 25mg PRN
.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*28 Capsule(s)* Refills:*0*
2. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK ([**Doctor First Name **]).
7. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day) for 14 days.
Disp:*140 ML(s)* Refills:*0*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 14 days: eat yogurt or probiotics while on
antibiotics.
Disp:*112 Capsule(s)* Refills:*0*
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Submental Abscess, mandibular periapical abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*New swelling of the area under your chin, or increased drainage
that is foul smelling. Fevers or chills. Any difficulty
breathing or feeling of swelling in your mouth.
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-29**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) **] in [**6-29**] days. You should call
his office at [**Telephone/Fax (1) 2349**] to schedule this.
|
[
"V45.81",
"522.5",
"528.3",
"521.09",
"414.00",
"V45.82",
"V70.7",
"V15.82",
"311",
"533.70",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"24.5",
"23.09",
"27.0"
] |
icd9pcs
|
[
[
[]
]
] |
10002, 10008
|
6086, 8389
|
355, 411
|
10103, 10103
|
3862, 6063
|
12349, 12502
|
2811, 2974
|
8730, 9979
|
10029, 10082
|
8415, 8707
|
10254, 11404
|
12030, 12326
|
2989, 3843
|
11436, 12015
|
270, 317
|
439, 2348
|
10118, 10230
|
2370, 2508
|
2524, 2795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,461
| 197,845
|
47086
|
Discharge summary
|
report
|
Admission Date: [**2113-2-22**] Discharge Date: [**2113-2-28**]
Date of Birth: [**2033-1-14**] Sex: M
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Black Stools
Major Surgical or Invasive Procedure:
1) Esophagogastroduedenoscopy with Clip Placements of a Gastric
Fundus Dieulafoy's Lesion.
2) Multiple Packed Red Blood Cell Transfusions.
History of Present Illness:
79 H/O BRBPR/PUD, C diff infection, CAD admitted to [**Hospital Unit Name 153**] with
melena. Ten years ago, the patient had BRBPR and was diagnosed
with stress ulcers of the upper GI tract after endoscopy. He had
concominant C diff diarrhea that time. He improved with C diff
ABX and PPI. The patient was then in his USOH until 3-4 days PTA
when he noticed onset of black stool. He reported orthostatic
dizziness. There was no nausea, vomiting, hematoemesis,
abdominal pain, or early satiety. He takes ASA, but no other
NSAIDs. He drinks a couple glasses of ETOH every few months. He
had a normal C-scope in [**2112-4-9**].
ED: Orthostatic hypotension. Heme stool negative. Then started
passing melena and BRBPR with GI prep. NGT lavage was revealed
blood and did not clear after 2 liters. He was transfused 2U
PRBC for a HCT of 40.
Past Medical History:
CAD/CABG ([**2102**]) with LVEF>70% ([**4-/2112**]), HTN, Hyperlipidemia,
BRBPR/PUD ([**2102**]), H/O C diff Colitis, PVD, H/O TIA and L ICA
Stenosis, OSA, Nephrolithiasis, S/P Choly.
Social History:
The patient lives with his wife in [**Name (NI) **]. His adult daughter
lives upstairs. He is currently working part-time as a
consulting engineer. He reports a 20 pack-year smoking history,
but quit in [**2065**]. He drinks an occasional glass of wine with
dinner.
Family History:
Non-contributory
Physical Exam:
PE on admission
VS: T 97.1 BP 137/60 HR 69 02Sat 98%
Gen: NAD
HEENT: EOMI, PERRLA, sclera anicteric, NGT in place
Neck: no JVD, no LAD
Chest: CTAB
CV: RRR s1/s2 no murmurs
Abd: soft NT/ND postive BS
Rectal: skin tags, guaiac postive black stools
Ext: no edema
Neuro: AAOx3
Pertinent Results:
[**2113-2-22**] 08:40PM HCT-38.0*
[**2113-2-22**] 05:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2113-2-22**] 05:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2113-2-22**] 05:25PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2113-2-22**] 05:25PM URINE MUCOUS-FEW
[**2113-2-22**] 02:45PM GLUCOSE-84 UREA N-31* CREAT-1.3* SODIUM-139
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-30* ANION GAP-12
[**2113-2-22**] 02:45PM ALT(SGPT)-29 AST(SGOT)-26 ALK PHOS-67 TOT
BILI-0.4
[**2113-2-22**] 02:45PM WBC-10.5 RBC-4.70 HGB-14.4 HCT-40.0 MCV-85
MCH-30.7 MCHC-36.1* RDW-13.6
[**2113-2-22**] 02:45PM NEUTS-70.8* LYMPHS-22.4 MONOS-4.6 EOS-1.4
BASOS-0.9
[**2113-2-22**] 02:45PM PLT COUNT-389
[**2113-2-22**] 02:45PM PT-13.2 PTT-25.3 INR(PT)-1.1
Brief Hospital Course:
1) UGIB: The patient was admitted to the [**Hospital Unit Name 153**] and an EGD showed
a Dieulafoy lesion in the gastric fundus with active bleeding -
4 hemoclips were placed with success. He received five PRBC
units in total in his early course and his HCT nadir was 27.
Early on, he had poor UOP and required IVF boluses. He has not
evidenced HCT stability (more than three stable HCTs Q8H) over
his early course, but his vital signs were stable. He was
continued on PPI IV BID. After transfer to the floor, his HCT
slowly downtrended. He was retransferred to the [**Hospital Unit Name 153**] for repeat
EGD and VS monitoring. The repeast EGD showed no active
bleeding. He remained stable thereafter with an uptrending HCT.
He was discharged with HCT checks.
2) CAD/HTN/Hyperlipidemia: The home cardiac regimen was
initially held in the face of his UGIB. He was then continued on
Carvedilol 12.5 mg PO BID, Telmisartan, Zocar 80 mg PO DAILY,
Zetia 10 mg PO DAILY, ASA 325 mg PO DAILY.
3) Depression: He was continued on Lexapro 10 mg PO DAILY.
Medications on Admission:
Lexapro 10mg qd
Zocar 80 qd
Zetia 10 mg
ASA 325 mg
Coreg 12.5 [**Hospital1 **]
Micardis 12.5/50
Discharge Medications:
1. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1) Blood Loss Anemia via Dieulafoy's Lesion of the Gastric
Fundus
Secondary Diagnosis:
2) History of Peptic Ulcer Disease.
3) History of Coronary Artery Disease.
4) Hypertension
Discharge Condition:
Good/Stable
Discharge Instructions:
1) Please call your doctor if you notice black stool or feel
dizzy or lightheaded. Call 911 to be transported immediately to
the Emergency Department if you vomit blood or notice red blood
in your stool.
Followup Instructions:
1) Please call your primary doctor [**Last Name (Titles) 7726**],[**First Name3 (LF) 177**] A. [**Telephone/Fax (1) 7728**])
to schedule an appointment with your primary care doctor for
this week. Please have you hematocrit (blood level) checked in
the next 5-7 days. Please have one more hematocrit check in the
next 12-14 days.
2) Here is a list of your other appointments:
Scheduled Appointments:
Provider [**Telephone/Fax (1) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2113-7-4**] 1:30
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2113-7-4**] 3:30
|
[
"537.84",
"401.9",
"272.4",
"428.0",
"V45.81",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
5197, 5203
|
3017, 4067
|
304, 446
|
5445, 5458
|
2142, 2994
|
5711, 6451
|
1816, 1834
|
4213, 5174
|
5224, 5224
|
4093, 4190
|
5482, 5688
|
1849, 2123
|
252, 266
|
474, 1310
|
5331, 5424
|
5243, 5310
|
1332, 1517
|
1533, 1800
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,916
| 167,548
|
33503
|
Discharge summary
|
report
|
Admission Date: [**2192-5-9**] Discharge Date: [**2192-5-19**]
Date of Birth: [**2119-8-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
central venous catheter insertion
History of Present Illness:
72 y/o woman with recently diagnosed cirrhosis and hemolytic
anemia complicated by acute cerebellar hemorrhage now transfered
to MICU for further workup and treatmenyt.
.
In [**2192-2-24**], during a routine nephrology visit for her CRI
she was found to have jaundice. Labs showed: AST 102, ALT 62,
thrombocytopenia, and indirect hyperbilirubinemia, with tbili
7.7, Indirect bili 5.5, haptoglobin < 20 and hct 24-26. She was
diagnosed with cryptogenic cirrhosis and hemolytic anemia;
outpatient workup by her PCP and hematology including negative
Hep serologies, [**Doctor First Name **] <1:40, -ANCA, low C3/C4 and including
negative cold agglutinins and negative combs test was
unrevealing. She underwent an outpatient BM biopsy was
complicated by bleeding requiring a transfusion.
.
She was admitted to [**Hospital **] Hospital on [**2192-5-4**] with
hypotension (60s systolic); which responded to fluid/PRBC
resucsitation. Her course was complicated by an NSTEMI (medical
managagement, preserved EF per echo). CT of her abdomen showed
liver nodularity suggestive of cirrhosis. Her INR was 2.0. She
was discharged with follow up, but re-presented to the ED dizzy
the next day ([**5-7**]) and was then transfered to [**Hospital1 18**] for further
work up at the request of her PCP.
Past Medical History:
Hyperlipidemia (simvastatin d/c'd in [**3-2**] after 15months)
Hypertension
AAA - currently 5.0cm, was 4.3 cm in [**10-30**]
COPD - long smoking history, quit 1.5 yrs ago
s/p CEA [**2190**]
Renal Artery Stenosis on right
Chronic Renal Insufficiency
Gastric ulcer age 20
"yellow jaundice" age 20
cryptogenic cirrhosis (diagnosis [**2-/2192**])
hemolytic anemia
Social History:
Lives with husband in [**Name (NI) **]. Has two daughters, several
grandchildren. Long smoking history, quit 1.5 yr ago. Dirnks [**1-25**]
glasses wine /night. No recent travel. no other drug use
Family History:
Mother, stroke age 40
Father: etoh cirrhosis
Sister: crytpogenic cirrhosis
Physical Exam:
VS: T 101.4, HR 124 (98-130), BP: 210/100 (decreased to ->145/90
with lopressor) (range: 127/52-167/80s), RR: 14, O2: 94% 2L NC
(had been 99% 2LNC)
GEN: in moderate distress, rigoring, moaning
HEENT: MM very dry, +scleral icterus, face symmetric, PERRL
CV: RRR, tachy
RESP: diminished, poor effort, no focal findings, some upper
airway sounds
ABD: diffusely tender, not distended, no rebound or guarding
EXT: LUE: in ace wrap wrist to shoulder
RUE: large hematoma/induration over forearm, quite tender to
palpation or movement.
LE's: in TEDS to knees
SKIN: + jaundice
NEURO: unable to assess cranial nerves (though face symmetric).
moves all 4, unable to assess strength or sensation
.
Pertinent Results:
Coombs: negative x 1, second test pending
Blood type O+, Ab screen negative
Factor 2, 5, 7: all low Inhibitor screen: negative
ACA: igG P; IgM: P; total IgG: slt elevation
Lupus Ab: neg, [**Doctor First Name **]: neg, AMA: neg, anti smooth: neg,
ceruloplasmin: wnl
HAV: IgG +, IgM: -
TIBC 178, B12 1453, Hapto: less than assay, Ferritin 801, TRF
137
SPEP: Neg, methylmalonic acid: pending
.
.
IMAGING:
.
CXR [**5-9**]: clear
.
ABD US [**5-9**]: 1. Echogenic liver consistent with fatty
infiltration. Please note that other forms of liver disease and
more advanced liver disease including significant hepatic
fibrosis and cirrhosis cannot be excluded on this study. Simple
cyst. 2. Cholelithiasis without evidence for cholecystitis. 3.
Small amount of ascites. 4. Previously identified (per patient)
5cm abdominal aortic aneurysm. Recommend comparison with prior
studies to evaluate for stability. Surgical consult should be
considered.
.
CT HEAD [**2193-5-11**]
There is a 3.6 x 2.0-cm well circumscribed hyperdense focus at
the superior aspect of the cerebellar vermis, above the fourth
ventricle. This likely represents a subdural hematoma, although
an intraparenchymal component cannot be excluded. There is
associated vasogenic edema.
There is no compression noted of the fourth ventricle or the
cerebellopontine cisterns. Prominence of the extra-axial CSF
spaces is likely due to age-related involutional changes. There
is no evidence of other hemorrhage, hydrocephalus, mass, shift
of midline structures, or large vascular territory infarction.
No
fractures are seen in the skull. Small amount of mucosal
thickening is seen in the left ethmoidal/sphenoidal region. The
orbits are unremarkable. Vascular calcifications are noted in
the cavernous carotid arteries.
IMPRESSION: Acute hemorrhage at the superior aspect of the
cerebellar vermis in the midline likely represents subdural
hematoma although possible intraparenchymal component cannot be
excluded. There is associated vasogenic edema. Currently there
is no compression on the fourth ventricle or the
cerebellopontine cisterns.
.
CT HEAD: [**2193-5-12**]
The known hyperdense collection along the cerebellar vermis is
unchanged compared to the initial CT from [**Month/Day/Year 13835**] 27 hours
prior, measuring 3.7 x 2.1 cm. Again the focus is at the
superior aspect of the cerebellar vermis and likely represents
subdural hematoma. There is mild associated vasogenic edema. No
evidence of
hydrocephalus. The remaining brain parenchyma is within normal
limits. Age-related involutional changes are again noted.
IMPRESSION: Unchanged subdural hematoma along the cerebellar
vermis with associated edema. No new hemorrhage.
.
MR HEAD: [**2192-5-14**]
FINDINGS: There is an [**Month/Day/Year 13835**] 40 x 22 mm intraparenchyma
hematoma in the cerebellar vermis along with surrounding edema.
There is no apparent enhancement within this lesion, and there
are no apparent underlying lesions. Followup MR [**First Name (Titles) **] [**Last Name (Titles) 13835**]
one month after the resolution of the hematoma would be helpful
to confirm the absence of underlying pathology. There are
several small high T2 signal foci in the deep and subcortical
white matter on FLAIR imaging consistent with small vessel
disease. There is T1 hyperintensity in the basal ganglia
suggestive of hepatic insufficiency. There are no incidental
bony or soft tissue abnormalities. CONCLUSION:
Acute cerebellar hematoma with surrounding edema as described
above. There are no apparent areas of enhancement or underlying
lesions, and a followup MRI in one month would be helpful to
assess resolution and also absence of underlying pathology.
.
B/L UE US: [**2192-5-14**]:
Though the history states bilateral upper extremity swelling,
the patient states only swelling focally within the left upper
extremity. There is no evidence of DVT involving either
extremity, there is a focal hematoma medially in the upper left
arm.
.
Brief Hospital Course:
72 y/o woman with HTN, HLP, CRI, COPD, admitted with hemolytic
anemia and decompensated ESLD.
.
On [**5-11**] she developed acute dysarthria; stat head CT showed
acute hemorrhage at the superior aspect of the cerebellar
vermis. She was transferred to the neurology ICU for spontaneous
SDH. She also developed a spontaneous large hematoma in her left
arm. Neurosurgery did not intervene on the SDH, it was stable on
repeat imagining. Vascular did not intervene on arm hematoma,
but recommended reversal of coagulpathy. She continued to have
falling Hct, thrombocytopenia, and coagulopathy.
.
Consults included:
Neurology and Neurosurgery (for acute SDH- no intervention)
Rheumatology (for ?vasculitis, thought unlikely),
Hepatology (for cirrhosis, rec outpatient liver f/u, and outpt
EGD)
Hematology (for hemolytic anemia/coagulopathy, thought to be due
to ESLD +/- mild DIC, rec plt goal 80-100, INR goal 1.5-1.7--no
note since [**5-14**])
Vascular surgery- no need to intervene on arm hematoma, rec
reversal of coagulopathy
.
She required multiple transfusions of blood products, including
9 units PRBCs, 11 units FFP, 6 units platelets
.
On [**5-16**] she developed GNR bacteremia and ARF, and underwent
significant clinical deterioration. She was intially covered
with broad spectrum antibiotics. Family meeting was held [**5-17**]
at 4:30 PM. Given patient's grave prognosis, her family decided
to change the goals of her care to be comfort measures only. Her
family wishes to transfer her to a facility that was closer to
her home.
Medications on Admission:
MEDS ON TRANSFER TO MICU TEAM:
Metoprolol Tartrate 5-10 mg IV Q4H:PRN SBP > 150
HydrALAzine 10-20 mg IV Q6H:PRN SBP>150
Metoprolol Tartrate 25 mg PO TID
IVF:40 mEq KCL/1000 mL D5W at 30 ml/hr
Albuterol PRN
Pantoprazole 40 mg IV q24
FoLIC Acid 1 mg PO DAILY
Potassium Chloride IV Sliding Scale
Insulin SC (per Insulin Flowsheet) Sliding Scale
Ursodiol 300 mg PO BID
Ipratropium Bromide Neb PRN
Discharge Medications:
1. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for agitation, anxiety.
2. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2
hours).
3. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q1H PRN ().
4. Morphine (PF) in D5W 100 mg/100 mL Parenteral Solution Sig:
One (1) 2-10 units/hr Intravenous INFUSION (continuous
infusion).
5. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Cirrhosis/decompensated liver failure
Hemolytic anemia
DIC
subdural hematoma
gram negative rod bacteremia
acute renal failure
Discharge Condition:
guarded
Discharge Instructions:
You are being transferred to another hospital per your family's
request to be closer to home. Our primary goal for your care is
for you to be comfortable.
Followup Instructions:
as per hospice
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
|
[
"410.72",
"403.90",
"038.49",
"496",
"348.39",
"286.6",
"431",
"584.9",
"571.5",
"287.5",
"585.9",
"283.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9532, 9547
|
7075, 8617
|
330, 366
|
9717, 9727
|
3092, 5185
|
9931, 10071
|
2293, 2370
|
9061, 9509
|
9568, 9696
|
8643, 9038
|
9751, 9908
|
2385, 3073
|
275, 292
|
394, 1680
|
5194, 7052
|
1702, 2064
|
2080, 2277
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,712
| 135,721
|
21579
|
Discharge summary
|
report
|
Admission Date: [**2193-8-26**] Discharge Date: [**2193-8-31**]
Date of Birth: [**2162-10-22**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Morbid Obesity
Major Surgical or Invasive Procedure:
Open Gastric bypass on [**2193-8-26**]
History of Present Illness:
[**Known firstname 698**] [**Known lastname 18691**] is a 30-year-old woman with longstanding
morbid obesity refractory to attempts at weight loss by
nonoperative means. Her preoperative screening weight here is
303.9 pounds. This together with her height of 59 inches
translates to a body mass index of 61.5 kilograms per meter
squared. Her previous attempts at weight loss have included
visits with a registered dietitian, Slim Fast, and Weight
Watchers.
Past Medical History:
depression
type 2 insulin-dependent diabetes mellitus
dyslipidemia
sleep apnea
chronic bronchitis
Klippel-Feil syndrome\
chronic low back pain
Social History:
The patient smokes one pack of cigarettes a day, but is
quitting. As of today, she does not drink or use drugs. She is
employed as an assistant at Verison.
Family History:
Mother-- stroke
Physical Exam:
ON admission:
Afebrile, 120/82, 94
GEN: obese, NAD, pleasant
HEENT: no icterus, PERRL
Neck: no thyromegaly or lymphadenopathy
Pulm: CTAB
CV: RRR
Abd: soft, NT/ND, normoactive bowel sounds, no masses
Extr: warm, trace edema
Pertinent Results:
[**2193-8-26**] 06:31PM BLOOD WBC-17.0*# RBC-4.38 Hgb-12.9 Hct-37.6
MCV-86 MCH-29.6 MCHC-34.5 RDW-13.5 Plt Ct-237
[**2193-8-27**] 02:39AM BLOOD WBC-11.0 RBC-4.53 Hgb-13.1 Hct-39.0
MCV-86 MCH-28.8 MCHC-33.5 RDW-13.8 Plt Ct-218
[**2193-8-28**] 03:29AM BLOOD WBC-9.9 RBC-4.30 Hgb-12.7 Hct-37.2 MCV-86
MCH-29.5 MCHC-34.2 RDW-13.6 Plt Ct-193
[**2193-8-29**] 03:57AM BLOOD WBC-10.1 RBC-4.24 Hgb-12.4 Hct-36.6
MCV-86 MCH-29.2 MCHC-33.7 RDW-13.4 Plt Ct-211
[**2193-8-26**] 06:31PM BLOOD Plt Ct-237
[**2193-8-27**] 02:39AM BLOOD Plt Ct-218
[**2193-8-28**] 03:29AM BLOOD Plt Ct-193
[**2193-8-29**] 03:57AM BLOOD Plt Ct-211
[**2193-8-26**] 06:31PM BLOOD Glucose-232* UreaN-11 Creat-0.9 Na-138
K-4.2 Cl-104 HCO3-20* AnGap-18
[**2193-8-27**] 02:39AM BLOOD Glucose-204* UreaN-8 Creat-0.6 Na-136
K-4.0 Cl-103 HCO3-23 AnGap-14
[**2193-8-27**] 09:01PM BLOOD K-3.6
[**2193-8-28**] 03:29AM BLOOD Glucose-193* UreaN-5* Creat-0.6 Na-137
K-3.9 Cl-103 HCO3-25 AnGap-13
[**2193-8-28**] 11:14AM BLOOD Glucose-146* UreaN-6 Creat-0.4 Na-140
K-3.5 Cl-104 HCO3-28 AnGap-12
[**2193-8-29**] 03:57AM BLOOD Glucose-139* UreaN-8 Creat-0.4 Na-139
K-3.8 Cl-103 HCO3-27 AnGap-13
[**2193-8-26**] 06:31PM BLOOD Phos-3.9 Mg-1.1*
[**2193-8-27**] 02:39AM BLOOD Calcium-8.4 Mg-1.7
[**2193-8-27**] 09:01PM BLOOD Calcium-7.8* Phos-3.1 Mg-1.7
[**2193-8-28**] 03:29AM BLOOD Calcium-7.8* Phos-3.0 Mg-1.9
[**2193-8-28**] 11:14AM BLOOD Calcium-8.0* Phos-1.7* Mg-2.0
[**2193-8-29**] 03:57AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
[**2193-8-29**] 04:11AM BLOOD Type-ART pO2-213* pCO2-54* pH-7.34*
calHCO3-30 Base XS-2
[**2193-8-26**] 05:14PM BLOOD Glucose-261* Lactate-3.6* Na-136 K-4.6
Cl-103
[**2193-8-29**] Upper GI Study-- Free passage of contrast through the
gastrojejunal anastomosis into the distal small bowel. No
evidence of leak or outlet obstruction.
[**2193-8-26**] Urine culture: negative
Brief Hospital Course:
This is a 30 year old female with morbid obesity who presented
for roux-en-y gastric bypass procedure. She underwent this
procedure on [**2193-8-26**], with a laparoscopic approach converted to
open (please see the operative note of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
full details). Post-operatively she was kept intubated given
concerns over her history of smoking and COPD. She was monitored
in the intensive care unit. She did not have a cuff-leak on
post-op day 1 and was therefore not extubated. She was however
succesfully extubated on post-op day 2. She had an upper GI
evaluation on post-op day 3 that demonstrated no leak or
stricture and she was started on a stage 1 diet. On post-op day
4 she was able to ambulate and her Foley was removed. She was
advanced to a stage 2 and 3 diet which she tolerated well. She
had no further respiratory issues after extubation. Her JP drain
was removed on post-op day 5 and she was discharged with planned
follow-up with Dr. [**Last Name (STitle) **]. All questions were answered to her
satisfaction upon discharge.
Medications on Admission:
Insulin
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*250 ML(s)* Refills:*0*
2. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2
times a day) for 1 months.
Disp:*600 ml* Refills:*0*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO twice a day
for 6 months.
Disp:*360 Capsule(s)* Refills:*0*
Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Morbid Obesity
Discharge Condition:
Tolerating stage 3 diet. Ambulating. Good pain control.
Discharge Instructions:
PLease take all medications as prescribed. Do not drive or
operate machinery while taking narcotic pain medications. Do not
drink with a straw. Continue on your stage 3 diet. You may
ambulate and shower. No heavy lifting for four weeks. You may
resume your home medications.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Where: [**Hospital6 29**]
BARIATRIC SURGERY Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2193-9-12**] 2:15
Provider: [**Name10 (NameIs) **] [**Doctor Last Name 28352**], LDN Where: [**Hospital6 29**] BARIATRIC
SURGERY Phone:[**Telephone/Fax (1) 28351**] Date/Time:[**2193-9-12**] 3:00
Completed by:[**2193-8-31**]
|
[
"780.57",
"V64.41",
"756.10",
"V13.01",
"998.2",
"491.9",
"278.01",
"250.00",
"272.4",
"311",
"V58.67"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.39"
] |
icd9pcs
|
[
[
[]
]
] |
4903, 4909
|
3350, 4454
|
311, 352
|
4968, 5025
|
1476, 3327
|
5349, 5755
|
1200, 1217
|
4512, 4880
|
4930, 4947
|
4480, 4489
|
5049, 5326
|
1232, 1232
|
257, 273
|
380, 841
|
1247, 1457
|
863, 1011
|
1027, 1184
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,037
| 157,729
|
37159
|
Discharge summary
|
report
|
Admission Date: [**2169-1-31**] Discharge Date: [**2169-2-5**]
Date of Birth: [**2120-7-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion, palpitations
Major Surgical or Invasive Procedure:
[**2169-1-31**] Mitral Valve repair (P2 resection and 34 mm [**Company 1543**]
ring)
History of Present Illness:
47 year old gentleman with a history of mitral valve prolapse
with mitral regurgitation who has been followed by serial
echocardiograms. Over the past year, his echocardiograms have
shown progressive dilation of the left ventricular end systolic
dimensions which is now at 44mm. Given the progression of his
MVP/mitral regurgitation, he has been referred for surgical
repair.
Past Medical History:
Anxiety
Lumbar disc disease
Mild Benign prostatic hypertrophy
s/p Esophageal dilatation
Social History:
Lives with: Mother
Occupation: [**Name (NI) **]. officer
Tobacco: Quit 18yrs ago after 15 pk yr hx
ETOH: 24 drinks/week
Family History:
Mother with AFIB/[**Name (NI) 19721**], Father with CAD/MI died at 78 (CVA)
Physical Exam:
Pulse: 110 Resp: 20 O2 sat: 100
B/P Right: 125/80 Left: 127/84
Height: 72" Weight: 200
General: NAD, fit, well-appearing
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X] anicteric sclera, OP benign
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 4/6 SEM throughout
precordium and radiating to carotids
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]no HSM/CVA tenderness
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Neuro: Grossly intact, non-focal, MAE, [**4-26**] strengths
Pulses:
Femoral Right/Left: 2+
DP Right/Left: 2+
PT [**Name (NI) 167**]/Left: 2+
Radial Right/Left: 2+
Carotid Bruit Right/Left: Murmur radiates to bilateral
carotids
Pertinent Results:
[**2169-2-4**] 08:25AM BLOOD WBC-5.3 RBC-3.87* Hgb-11.9* Hct-34.5*
MCV-89 MCH-30.8 MCHC-34.6 RDW-12.4 Plt Ct-264#
[**2169-2-2**] 05:05AM BLOOD Glucose-105* UreaN-13 Creat-0.8 Na-138
K-4.3 Cl-105 HCO3-27 AnGap-10
[**2169-2-4**] 08:25AM BLOOD UreaN-11 Creat-0.8 K-4.5
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
aortic root is moderately dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are elongated. There is moderate/severe mitral valve prolapse.
There is partial mitral leaflet flail. The mitral regurgitation
vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results on [**2169-1-31**] at 820am.
Post bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine and epinephrine. Biventricular systolic function
is unchanged. Annuloplasty ring seen in the mitral position.
Leaflets move well and the annuloplasty ring appears well
seated. Trivial central mitral regurgitation present. Mean
gradient across the mitral valve is 4 mm Hg. Aorta appears
intact post decannulation.
Brief Hospital Course:
Admitted same day surgery and underwent mitral valve repair.
See operative report for further details. He received cefazolin
for perioperative antibiotics. Postoperatively he was
transferred to the intensive care unit for management. In first
twenty-four hours he was weaned from sedation, awoke
neurologically intact, and was extubated without complications.
He was transfered to the floor on post operative day one for the
remainder of his stay. Physical therapy worked with him on
strength and mobility. He did have a brief episode of atrial
fibrillation which converted to SR with amiodarone. He remained
in sinus rhythm. He continued to do well and was ready for
discharge home on post operative day five.
Medications on Admission:
lorazepam 0.5 mg [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety .
Disp:*60 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO q3h as
needed for pain.
Disp:*28 Tablet(s)* Refills:*1*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 1 week, then 200mg [**Hospital1 **] x 1 week, then 200mg
daily until further instructed.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Mitral Regurgitation, s/p MV repair
Mild Benign Prostatic Hypertrophy
Anxiety
Discharge Condition:
Alert and oriented x3
Ambulating with steady gait
Sternal pain managed with dilaudid
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2169-3-9**] 1:00
Please call to schedule appointments
Primary Care Dr.[**Last Name (STitle) 33667**] in [**12-24**] weeks [**Telephone/Fax (1) 81613**]
Cardiologist Dr. [**Last Name (STitle) 3497**] in [**12-24**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2169-2-5**]
|
[
"V43.65",
"427.31",
"V45.4",
"300.00",
"600.00",
"V15.82",
"429.5",
"V26.52",
"722.10",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61",
"35.32"
] |
icd9pcs
|
[
[
[]
]
] |
5435, 5493
|
3665, 4384
|
354, 441
|
5615, 5702
|
2021, 3642
|
6242, 6713
|
1113, 1191
|
4468, 5412
|
5514, 5594
|
4410, 4445
|
5726, 6219
|
1206, 2002
|
281, 316
|
469, 847
|
869, 959
|
975, 1097
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,995
| 180,538
|
7251
|
Discharge summary
|
report
|
Admission Date: [**2151-11-18**] Discharge Date: [**2151-11-30**]
Date of Birth: [**2078-5-30**] Sex: F
Service: MEDICINE
Allergies:
Glucophage / Morphine / Codeine / Heparin Agents / Betadine
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Weakness, fatigue, draining leg wound
Major Surgical or Invasive Procedure:
PICC line placement under fluoro
History of Present Illness:
Pt is a 73 yo F w/ an extensive medical Hx including DMII, PVD,
s/p fem-[**Doctor Last Name **] bypass in [**Month (only) **], visual loss, EtOH cirrhosis,
esophageal varicies, now presents with worsening renal failure
and generalized weakness and fatigue for several days. She
states that she has not eaten or drinkin in approx 1.5 days. In
addition, there has been serous drainage from the surgical wound
in her [**Month (only) **]. She denies any severe pain in her leg. She also
denies chest pain, SOB, dizziness, or light-headednes. She does
complain of LLQ abdominal pain.
In the ED, the patient got 2L of NS, and blood and urine
cultures were sent.
Past Medical History:
1. DM II
2. TIA with R visual loss
3. Alcoholic cirrhosis, with esophageal varicies (grade I) noted
on EGD [**11-21**]. EGD also disclsoed erythema and mosaic appearance
in the whole stomach compatible with gastritis versus portal
hypertensive gastropathy.
4. Chronic pancreatitis secondary to ETOH abuse
5. Splenomegaly
6. Hypercholesterolemia
7. Pancytopenia, followed by Dr. [**Last Name (STitle) **].
Previous workup included assessment for iron deficiency, B12,
or folate deficiency, all of which were within normal limits.
Coombs test was negative, though haptoglobin has been <20.
Bone marrow bx was negative for MDS. A prior workup for PNH
was negative.
8. HTN
9. Peripheral [**Last Name (STitle) 1106**] diseaes, with chronic ischemia L leg
(recent surgery as above)
10. Bilateral carotid stenoses, s/p CEA in [**2144**] and [**2146**]
11. S/p cholecystectomy, [**1-17**]
12. S/p appendectomy
13. S/p hysteroscopy with D&C for post-menopausal bleeding, [**6-19**]
14. S/p L oophorectomy for L ovarian cyst
15. Cataracts
16. Breast nodule, bx in [**2142**] was benign
Social History:
The patient has a history of heavy alcohol use for >20 years.
She
quit drinking in [**2128**]. She has a 40 pack yr h/o tobacco use,
and
she quit smoking 8 years ago. She lives alone. She has a
daughter who lives in [**Name (NI) 108**]
Family History:
Notable for FH of colorectal cancer. Patient reports that the
following relatives were diagnosed with colon cancer:
Mother, dx in 60s; Father, dx in 60s; Brother, dx in 60s;
Maternal grandmother, not sure when she was dx; Maternal uncle,
died at age 49. As noted above, patient denies history of
bleeding disorders.
Physical Exam:
PE: 94.8 70 18 140/82 100%RA
GEN: Pt appears fatigued, lying in bed. She is able to answer
questions. NAD
HEENT: MM dry. PERRL OP clear w/ no exudates
CV: RRR. [**2-22**] late-peaking systolic murmur heard best at RUSB
Resp: CTAB
Abd: Slightly distended w/ + fluid wave. + BS. Slightly tender
at LLQ.
Ext: [**Month/Day (4) **] wound draining serous fluid. Wound is separated with
surrounding erythema.
Pertinent Results:
[**2151-11-18**] 10:58PM URINE HOURS-RANDOM UREA N-575 CREAT-81
SODIUM-LESS THAN
[**2151-11-18**] 10:58PM URINE COLOR-AMBER APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2151-11-18**] 10:58PM URINE BLOOD-LG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2151-11-18**] 10:58PM URINE EOS-POSITIVE
[**2151-11-18**] 05:36PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2151-11-18**] 05:36PM URINE BLOOD-LG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2151-11-18**] 05:36PM URINE RBC-[**6-26**]* WBC-[**3-21**] BACTERIA-FEW
YEAST-NONE EPI-0
[**2151-11-18**] 11:49AM GLUCOSE-152* LACTATE-4.2* NA+-130* K+-4.7
CL--107 TCO2-13*
[**2151-11-18**] 11:30AM GLUCOSE-160* UREA N-100* CREAT-2.6*
SODIUM-129* POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-12* ANION
GAP-21*
[**2151-11-18**] 11:30AM ALT(SGPT)-16 AST(SGOT)-58* LD(LDH)-280* ALK
PHOS-121* TOT BILI-1.2
[**2151-11-18**] 11:30AM ALBUMIN-2.8*
[**2151-11-18**] 11:30AM CALCIUM-8.2* PHOSPHATE-6.8*# MAGNESIUM-2.4
[**2151-11-18**] 11:30AM WBC-6.0 RBC-3.27* HGB-10.5* HCT-30.5* MCV-93
MCH-32.1* MCHC-34.4 RDW-18.1*
[**2151-11-18**] 11:30AM NEUTS-79.7* BANDS-0 LYMPHS-13.0* MONOS-2.5
EOS-4.5* BASOS-0.3
[**2151-11-18**] 11:30AM ANISOCYT-2+ MACROCYT-1+
[**2151-11-18**] 11:30AM PLT SMR-VERY LOW PLT COUNT-40*#
[**2151-11-18**] 11:30AM PT-21.1* PTT-41.8* INR(PT)-2.1*
Brief Hospital Course:
#[**Month/Day/Year **] wound:
In the ED, [**Month/Day/Year **] surgery saw the patient, and felt that the
wound was not infected, and should be handled with general wound
care. On the floor, the wound drained copious amounts of serous
flluid. A wound consult was ordered. The wound care nurse
recommended a wound vac, however [**Month/Day/Year 1106**] surgery did not felt
this was pertinent at this time.
#ARF:
Upon admission, the patient was found to have a Cr=2.3 which is
above her basline. There was question of whether this ARF was
prerenal, or due to hepatorenal syndrome. The patient was also
found to have a metabolic acidosis, with a lactate of 4,
suggesting sepsis. The patient was given 2 L NS in the ED, and
was infused with HCO3- and NS while on the floor. Over the first
night of her admission, the patient received 1300cc and put out
100cc. On the second day of her admission, her lytes normalized
with Na going from 129 to 132 and Cr from 2.6-2.2 suggesting a
prerenal picture. Dialysis not started.
#Cirrhosis:
The patient presented with a small rise in her LFT's, and
ascites. She had an abdominal US which showed patend venous
flow, and some ascites. She became encephalopathic. Due to
[**Hospital 7235**] medical problems, patient and family decided to stop
treatment and was made CMO. Pt was placed on fentanly gtt and
scopalamine patch and died within 48 hours.
Medications on Admission:
Atenolol
Levaquin
Linezolid
Flagyl
Colace
Coumadin
Fosamax
ASA
Calcium carbonate
Nortrirtyline
Avandia
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
|
[
"440.20",
"585.6",
"486",
"433.30",
"789.2",
"041.7",
"572.3",
"E878.8",
"276.2",
"537.9",
"577.1",
"456.21",
"995.91",
"284.1",
"E849.7",
"998.32",
"366.9",
"584.9",
"287.5",
"998.83",
"305.1",
"038.9",
"E879.8",
"433.10",
"571.2",
"572.8",
"303.91",
"428.0",
"250.70",
"403.91",
"E849.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"34.91",
"99.04",
"93.59",
"96.07",
"38.93",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
6268, 6277
|
4696, 6085
|
359, 393
|
6329, 6339
|
3226, 4673
|
6392, 6399
|
2466, 2784
|
6239, 6245
|
6298, 6308
|
6111, 6216
|
6363, 6369
|
2799, 3207
|
282, 321
|
421, 1081
|
1103, 2193
|
2209, 2450
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,431
| 165,193
|
23490
|
Discharge summary
|
report
|
Admission Date: [**2142-10-7**] Discharge Date: [**2142-10-26**]
Date of Birth: [**2071-10-8**] Sex:
Service:
HISTORY OF PRESENT ILLNESS: This 70-year-old female with a
known history of coronary artery disease status post
myocardial infarction in [**2135**] had a normal ejection fraction
at that time of 60 percent. She had shortness of breath and
a hematocrit of 20 in the recent past with a resulting chest
pain. This drop in hematocrit required six units of blood
products transfusion. Echocardiogram revealed at that time
severe pulmonary hypertension and worsening mitral valve
regurgitation. The patient had an apparent history of
gastrointestinal arteriovenous malformation which could be
problem[**Name (NI) 115**] for any operative anticoagulation long-term with
the potential need for mechanical valve. The patient also
was status post thoracentesis on [**2142-10-4**], three days prior
to admission, with 500 cc removed.
PAST MEDICAL HISTORY: Arteriovenous malformation of
gastrointestinal tract ascending colon.
Diverticulitis with internal hemorrhoids.
Coronary artery disease with myocardial infarction in [**2135**].
Pseudogout.
Osteoporosis.
Anemia.
Fibromyalgia.
Gastroesophageal reflux disease.
Chronic renal insufficiency.
PAST SURGICAL HISTORY: Three total hip arthroplasties.
Back surgery.
Total abdominal hysterectomy.
Colonoscopy with endoscopy last week for polyp removal.
MEDICATIONS AT HOME:
1. Cozaar 12.5 mg p.o. once daily.
2. Metoprolol 12.5 mg p.o. once daily.
3. Zocor 20 mg p.o. once daily.
4. Nitro paste half inch every six hours.
5. Neurontin 300 mg p.o. twice daily.
6. Trazodone 600 mg p.o. at bedtime.
7. Metoclopramide which was on hold.
8. Colchicine on hold.
9. Ativan 0.5 mg to 1 mg p.o. at bedtime.
10. Aspirin 81 mg had been stopped since [**2142-9-29**].
11. [**Doctor First Name **] 60 mg p.o. once daily.
12. Aciphex 20 mg p.o. twice a day.
ALLERGIES: The patient was allergic to penicillin for which
she had anaphylaxis and morphine which gave her an itch.
SOCIAL HISTORY: She had no smoking or alcohol history.
PHYSICAL EXAMINATION: On examination at admission,
temperature was 97.8, heart rate 67, respiratory rate 18,
blood pressure 122/57, sating 95 percent on room air. She
was alert and oriented in no apparent distress. Her lungs
were clear bilaterally. She had S1, S2 with a holosystolic
murmur. Abdomen was soft, nontender and nondistended with
positive bowel sounds. Her extremities were warm and well
perfused without any swelling or cellulitis. She was guaiac
negative on a rectal examination.
Th[**Last Name (STitle) 1050**] was admitted to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] service for
preoperative evaluation for her known coronary artery disease
for potential mitral valve repair versus replacement and
coronary artery bypass graft. Gastrointestinal consultation
was requested to evaluate the patient's six unit
gastrointestinal bleed with known arteriovenous malformation
of her colon in light of the need for heparinization
systemically for cardiopulmonary bypass. The patient was
seen by general surgery team, which also recommended the SB
capsule endoscopy and whether or not it was reasonable to re-
scope the patient or just do a capsular camera study to
evaluate her intestinal tract. This was discussed with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He recommended a gastrointestinal evaluation
with repeat esophagogastroduodenoscopy and colonoscopy and
then a capsule study as planned. On house day two, the
patient had some mild mid chest pain with radiation to her
left back. She was in sinus rhythm with a stable
hemodynamically sating 98 percent on room air. She continued
on Lopressor, Zocor, gabapentin, [**Doctor First Name **], Protonix and her
nitroglycerin paste. She was awaiting a chest x-ray,
echocardiogram and labs as well as cardiology consultation
and final recommendations from the gastrointestinal service.
The patient was seen by cardiology. In preparation for her
workup, a cardiac catheterization showed 90 percent osteal
ramus branch stenosis. Echocardiogram was ordered to
evaluate her mitral valve and rule out any endocarditis. The
patient continued on her beta blocker. Recommendations from
cardiology were appreciated. The patient was also seen by
gastrointestinal medical fellow, Dr. [**First Name (STitle) 437**]. Results of the
gastrointestinal consultation was that it would be necessary
to have the patient have a capsule camera study of her
intestinal tract. The patient was also seen in consultation
by case management and the hepatobiliary surgery team and
actually waited on the service for approximately a week
awaiting the SB capsule study. The patient remained stable
on the service. She had an echocardiogram which showed
moderate to severe mitral regurgitation with preserved
ejection fraction which was improved from her echocardiogram
at the outside hospital at [**Hospital3 1280**]. Cardiology
recommendations were also appreciated by Dr. [**Last Name (STitle) **], and
this was also discussed with Dr. [**Last Name (Prefixes) **] and Dr. [**Last Name (STitle) 1295**]
from cardiology. The decision was made to bring the patient
to the operating room for mitral valve replacement, coronary
artery bypass graft, as ramus stenosis predated the MR and
was not felt to be contributory. The patient remained on the
floor without any gastrointestinal bleeding over the next
several days awaiting the arrival of the capsule. The
patient also had some complaints of right shoulder pain, but
this was evaluated as well as her anemia. Her capsule study
continued to be delayed due to no availability of a
cardiology capsule. The creatinine remained stable at 1.3.
The hematocrit was 36.9. On house day four, the patient was
also consulted by the dental service as we waited for the
arrival of the small bowel capsule. The patient was also
seen by case management. The patient also said that her
shoulder pain predated this admission, and it was treated
with Tylenol number 3 in the hospital. A dental consultation
was scheduled for [**10-12**] as well as a Panorex film of
the mouth to rule out any occult dental disease. The patient
was cleared by dental on [**2142-10-12**] for her valve
replacement. The capsule arrived on [**2142-10-15**], and the
patient was scheduled to have the small bowel capsule study
on the following morning. Preliminary [**Location (un) 1131**] of the results
of the capsule study on [**2142-10-17**] were two cecal colonic
arteriovenous malformations which were not actively bleeding
and a foreign body in the small bowel with a question of
fibrous material versus the coffee stirring straw.
Pr[**Last Name (STitle) **]tive labs are as follows: Sodium 140, potassium 0.0,
chloride 106, bicarb 27, BUN 12, creatinine 1.2 with a blood
sugar of 91, white count 3.9, hematocrit 34.8, platelet count
262, magnesium 2.1. Urinalysis was negative. The patient's
hematocrit remained stable. Electrocardiogram showed sinus
bradycardia. Chest x-ray showed bilateral small effusions
with some apical scarring. On [**2142-10-19**], the patient went
to the operating room with Dr. [**Last Name (Prefixes) **] and underwent
coronary artery bypass grafting times one and mitral valve
replacement with a vein graft to the ramus and a 25 mm
[**Company 1543**] Mosaic porcine valve. The patient was transferred
to cardiothoracic Intensive Care Unit in stable condition on
Neo-Synephrine drop at 0.3 mcg/kg/minute, propofol drip at 20
mcg/kg/minute and an epinephrine drip at 0.02 mcg/kg/minute.
On postoperative day one, the patient was hemodynamically
stable with blood pressure of 137/89 in sinus rhythm at 87.
She had been extubated overnight and remained on
nitroglycerin drip at 2.5 mcg/kg/minute and an epinephrine
drip at 0.01 mcg/kg/minute. Postoperative labs as follows:
White count 15.1, hematocrit 37.1, platelet count 167,000,
potassium 4.6, BUN 11, creatinine 1.0. The patient had a
neurologically nonfocal examination. She had decreased
breath sounds at both bases. Incisions were clean, dry and
intact. The patient was doing very well. She began Lasix
diuresis.
On postoperative day two, Lopressor was also added in. The
Swan-Ganz though was removed. Nitroglycerin and epinephrine
were both weaned to off. The patient started her aspirin
therapy, and Lopressor was increased to 37.5 twice a day and
continued with Lasix. Creatinine remained stable at 1.0.
The central line was removed after placement of peripheral
line. The patient was switched over the Vicodin p.o. for
pain relief of her incisional discomfort. Pacing wires
remained in place.
On postoperative day three, the patient was transferred out
from the CSRU. Her heart rate dropped to the 50s. Lopressor
was decreased to 12.5 b.i.d. She had been restarted on her
Neurontin for her chronic fibromyalgia pain. White count
dropped to 7.7, and hematocrit remained stable at 27.5 with a
creatinine up slightly to 1.3. Her examination was
unremarkable. Incisions were clean, dry and intact. She was
alert and oriented. Pacing wires remained in. The patient
was seen and evaluated by physical therapy on the floor and
encouraged to continue working towards increased ambulation
and independence. The patient was slowly improving. Her
Ativan was decreased as the patient was sleepy. She was
encouraged to ambulate and increase her p.o. intake. Her
Lopressor was increased slightly again to 25 p.o. b.i.d.
Planning was begun for discharge to home. Pacing wires were
discontinued without incident. The patient was noted to have
an AV conduction delay and was re-consulted by cardiology and
seen by an electrophysiologist for her prolonged PR interval.
They recommended discontinuing the beta blocker, and no
pacemaker was indicated. The patient was instructed to
follow up with Dr. [**First Name (STitle) **] at [**Hospital6 3872**] and
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5051**] who is the
electrophysiologist at [**Hospital6 3872**].
On postoperative day five, the patient had a block on the
morning of the 24th, but was asymptomatic and was still
complaining of some chest pain. Lopressor was discontinued
according to EP recommendation. The Lasix was decreased to
20 b.i.d., and the patient was already at her preoperative
weight. Creatinine rose slightly to 1.5. Pacing wires had
already been removed. The patient continued to work with
physical therapy to improve her activity level and was
tolerating advancement of her diet. The patient was also
encouraged to cough and deep breath to improve her pulmonary
toilet and be seen by the EP fellow on the 25th on the day
prior to discharge who noted that the AV prolongation of the
PR of 0.36 and 0.34 were stable. The patient was again
instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5051**] at [**Hospital6 33180**] on the recommendation of Dr. [**Last Name (STitle) 13177**] of
electrophysiology.
On postoperative day six, the patient was clinically doing
very well; although, she seemed a little weak and anxious and
did not want to go home. Her hematocrit was normal, and the
patient was encouraged to go ahead with the discharge
planning for the following morning and a plan to decrease her
narcotics.
On postoperative day seven, her hematocrit rose slightly from
1.5 to 1.6. She was still complaining of a little bit of
incisional pain for which she was receiving Vicodin p.r.n.
She was also started on iron and vitamin C with plans to
allow her to go home on the 26th and follow up with her
primary care or cardiologist for creatinine check next week
while she was at home. She was discharged on the 26th to
home with [**Hospital6 407**] services with the
following discharge diagnoses:
Status post mitral valve replacement and coronary artery
bypass grafting times one with porcine valve.
Arteriovenous malformation of the gastrointestinal tract.
Status post foreign body of the intestinal tract.
Diverticulitis with internal hemorrhoids.
Myocardial infarction.
Pseudogout.
Osteoporosis.
Anemia.
Fibromyalgia.
Gastroesophageal reflux disease.
Renal insufficiency.
First degree heart block.
The patient was discharged with the following instructions:
Follow up with Dr. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) **], her primary care
physician, [**Name10 (NameIs) **] approximately 1-2 weeks and to have a
creatinine check.
Follow up with Dr. [**First Name (STitle) **] her cardiologist at [**Hospital3 1280**] in 1-
2 weeks.
Post discharge to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5051**], her
electrophysiologist at [**Hospital6 3872**], in [**12-1**]
weeks.
[**Last Name (Prefixes) 60167**] in the office four weeks postoperatively
for her postoperative surgical check.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Gabapentin 300 mg p.o. three times a day.
3. Zantac 150 mg p.o. twice a day.
4. Enteric coated aspirin 81 mg p.o. once daily.
5. Trazodone 600 mg p.o. at bedtime.
6. Zocor 20 mg p.o. once daily.
7. Hydrocodone - acetaminophen 5/500 mg tablet 1-2 tablets
p.o. p.r.n. every six hours for pain.
8. Niferex 150/50 mg capsule one capsule p.o. once daily
times one month.
9. Vitamin C 500 mg p.o. twice daily for one month.
10. Folic acid 1 mg p.o. once daily for one month.
The patient was discharged to home on [**2142-10-26**] in stable
condition.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2142-12-19**] 15:19:08
T: [**2142-12-19**] 16:10:01
Job#: [**Job Number 60168**]
|
[
"593.9",
"280.9",
"733.00",
"729.1",
"569.84",
"V43.64",
"426.11",
"411.1",
"424.0",
"414.01",
"416.8",
"719.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"45.19",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
11939, 12998
|
13021, 13871
|
1460, 2067
|
1303, 1439
|
2147, 11917
|
158, 959
|
982, 1279
|
2084, 2124
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,793
| 105,415
|
35605
|
Discharge summary
|
report
|
Admission Date: [**2129-6-28**] Discharge Date: [**2129-6-29**]
Date of Birth: [**2064-1-17**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
pericardial effusion
Major Surgical or Invasive Procedure:
Aborted PCI
Pericardiocentesis
Cardioversion
History of Present Illness:
65-year-old male with paroxysmal atrial fibrillation and was s/p
PVI at [**Hospital3 **] Medical Center in [**2124**]. Since then, he
was treated with low dose Flecainide with occasional break
through atrial fibrillation until a few weeks ago when he
developed atrial fibrillation with rapid ventricular response
and wide QRS complex. His Flecainide was discontinued and he
was started on Metoprolol as well as Xarelto for
anticoagulation. He has been taking the Xarelto daily since
[**5-4**] with no missed doses. He was scheduled for
cardioversion at the end of [**Month (only) 547**], however converted
spontaneously and is now referred for repeat pulmonary vein
isolation procedure. Of note, the patient self stopped Xarelto
with last dose on Sat [**6-25**].
The patient went for the repeat PVI on [**6-28**]. Prior to PVI he
developed pericardial effusion without clear evidence of
perforation. This was in the setting of getting 10,000 units of
heparin. Interventional cardiology was called and did a
pericardiocentesis with 250 cc of bright red blood returned. A
drain was placed. TTE following the procedure showed trivial
effusion and the drain was without accumulation. He was started
on colchicine and sent to CCU for further monitoring and
evaluation.
On arrival to the floor, patient slightly somnolent complaining
of chest soreness around pericardial drain.
REVIEW OF SYSTEMS
Per HPI. Currently, feels soreness around pericardial drain
site.
Past Medical History:
- paroxysmal atrial fibrillation s/p PVI [**2124**]
- hypertension
- prostate cancer - followed conservatively
Social History:
Married and works repairing medical equipment.
Tobacco: none
ETOH: [**3-11**] drinks/night
Illicits: none
Family History:
mother has atrial fibrillation at age [**Age over 90 **].
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 97.2 BP= 96/57 HR= 66 RR= 19 O2 sat= 100% RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. No xanthalesma.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Anterior examination.
ABDOMEN: Soft, NTND. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Warm, well perfused. 2
sheaths in left groin, no hematoma present.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial 2+, DP 2+
Left: Carradial 2+, DP 2+
DISCHARGE PHYSICAL EXAM:
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Clear : )
Abdominal: Soft, Non-tender, No(t) Distended
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Sedated, Tone: Not assessed
Pertinent Results:
Admission Labs:
[**2129-6-28**] 07:00AM BLOOD WBC-6.0 RBC-5.04 Hgb-15.8 Hct-49.5 MCV-98
MCH-31.4 MCHC-32.0 RDW-12.8 Plt Ct-267
[**2129-6-28**] 07:00AM BLOOD Neuts-63.0 Lymphs-28.6 Monos-5.4 Eos-1.8
Baso-1.3
[**2129-6-28**] 01:51PM BLOOD Hct-42.8
[**2129-6-29**] 03:49AM BLOOD WBC-7.2 RBC-3.95* Hgb-12.7*# Hct-39.4*
MCV-100* MCH-32.0 MCHC-32.1 RDW-12.9 Plt Ct-207
[**2129-6-28**] 07:00AM BLOOD PT-12.2 PTT-37.2* INR(PT)-1.1
[**2129-6-28**] 07:00AM BLOOD Glucose-119* UreaN-19 Creat-1.0 Na-144
K-4.2 Cl-108 HCO3-29 AnGap-11
[**2129-6-29**] 03:49AM BLOOD Glucose-110* UreaN-21* Creat-1.1 Na-141
K-4.2 Cl-106 HCO3-26 AnGap-13
[**2129-6-29**] 03:49AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.9
Pericardial Fluid
[**2129-6-28**] 10:50AM OTHER BODY FLUID WBC-7600* Hct,Fl-34* Polys-78*
Lymphs-18* Monos-4*
[**2129-6-28**] 10:50AM OTHER BODY FLUID TotProt-3.8 Glucose-110
LD(LDH)-179 Amylase-23 Albumin-2.8
[**2129-6-28**] 10:50 am FLUID,OTHER PERICARDIAL.
GRAM STAIN (Final [**2129-6-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2129-6-29**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
[**2129-6-28**] 10:50 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERICARDIAL.
Fluid Culture in Bottles (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2129-6-29**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by [**Doctor Last Name 13478**],J (CCU)[**2129-6-29**] AT
1017.
ECHO ([**6-28**]):
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad. There
are no echocardiographic signs of tamponade.
No prior study available for comparison.
ECHO ([**6-29**]):
Focused study s/p pericardiocentesis: There is trivial
pericardial effusion of no hemodynamic significance located
anteriorly to the right and left ventricle.
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
65-year-old male with atrial fibrillation who presented for
pulmonary vein isolation complicated by pericardial effusion.
ISSUES:
# Pericardial effusion: Likely complication of heparin bolus
and micro-perforation during procedure. He underwent
pericardiocentesis with a drain placement. Repeat TTE
demonstrated little pericardial fluid and drain was removed.
Echo on day of discharged showed only trivial pericardial
effusion. Colchicine (10d course) was initiated for pericarditis
prophylaxis. No evidence of HD instability.
# Atrial fibrillation: s/p aborted pulmonary vein isolation
procedure complicated by pericardial effusion. The patient
underwent electrical re-synchronization. He is anticoagulated
with rivaroxaban. He will need to continue his antiplatelet
medications upon discharge and follow up for a repeat pulmonary
vein isolation procedure. Sheaths were removed without
complication. Held metoprolol while in house for relative
hypotension, and discharged on succinate metoprolol 25mg qd. EP
follow up should be scheduled within 1-2 weeks.
# HTN: Patient was on metoprolol succinate and losartan as
outpt. These meds were held due to relative hypotension on
admission. The patient was discharged home with metoprolol
succinate 25mg qd.
TRANSITIONAL ISSUES:
1. FOLLOW-UP
Instructions to the patient, "Dr.[**Name (NI) 29750**] office will call
you with an appointment. If you do not hear from them in 1 week
please call [**Telephone/Fax (1) 62**]. Please see your primary care physician
[**Name Initial (PRE) 176**] 1 week of discharge. The number to set up the appointment
is [**Telephone/Fax (1) 12551**] (YEGHIAZARIANS, VARTAN)".
2. Follow-up pericardial fluid cultures: One bottle showed GRAM
POSITIVE COCCI IN PAIRS AND CLUSTERS, the other bottle
demonstrated no growth (preliminary read). We deferred on
treatment considering most likely a contaminant, but the second
bottle final read needs to be followed up.
3. Titrate losartan and metoprolol if hemodynamics tolerate in
outpatient setting.
Medications on Admission:
LOSARTAN - 100 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet - 1 Tablet(s) by mouth twice
a day
RIVAROXABAN [XARELTO] - 20 mg Tablet - 1 Tablet(s) by mouth once
a day
ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg Tablet Extended
Release - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. rivaroxaban 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
atrial fibrillation
pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pulmonary vein isolation as treatment of
your atrial fibrillation. During the procedure it was noted that
you had a fluid collection around your heart. This was likely a
complication of your procedure. You had this drained and
multiple ultrasounds of your heart which showed that the fluid
was not reaccumulating.
While you were here you had a cardiac resynchronizion with
return in your heart rate to a normal rhythm.
Your blood pressure was a little low while you were here. You
should stop your losartan until you follow up with your primary
care physician and he gives you instructions on if you should
restart this medication. Your metoprolol succinate dose will be
decreased. Again, you should follow up with your primary care
physician to see if this can be changed back to your previous
levels. You should continue your aspirin and rivaroxaban as
previously prescribed. Please take your medications as listed on
the attached sheet.
Followup Instructions:
Dr.[**Name (NI) 29750**] office will call you with an appointment. If you
do not hear from them in 1 week please call [**Telephone/Fax (1) 62**].
Please see your primary care physician [**Name Initial (PRE) 176**] 1 week of
discharge. The number to set up the appointment is [**Telephone/Fax (1) 12551**]
(YEGHIAZARIANS, VARTAN)
|
[
"185",
"423.9",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"37.0",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
8884, 8890
|
5920, 7202
|
292, 339
|
8975, 8975
|
3673, 3673
|
10114, 10447
|
2101, 2160
|
8377, 8861
|
8911, 8954
|
7994, 8354
|
9126, 10091
|
2175, 2185
|
4955, 4955
|
4986, 5897
|
2207, 2900
|
7223, 7968
|
232, 254
|
367, 1828
|
3689, 4740
|
4824, 4918
|
8990, 9102
|
1850, 1962
|
1978, 2085
|
4772, 4787
|
2925, 3654
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,630
| 168,721
|
47080
|
Discharge summary
|
report
|
Admission Date: [**2181-2-18**] Discharge Date: [**2181-3-1**]
Date of Birth: [**2110-6-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2181-2-23**] - Mitral valve repair with a triangular resection of the
middle scallop of the posterior leaflet (P2) and mitral valve
annuloplasty with a 32-mm St. [**Hospital 923**] Medical saddle ring.
History of Present Illness:
This is a 70 year old male who presented to his PCP several
months ago with complaints of weight loss and lower extremity
edema. He was noted to have heart murmur and found to be in
atrial fibrillation. Subsequent echocardiogram revealed mitral
valve prolapse with significant regurgitation, and some degree
of aortic stenosis. Over the last several months, his pedal
edema has improved with medical therapy. He denies any history
of SOB at rest and chest pain but does admit to DOE. His weight
has remained stable for the last two months and
patient/family reports that workup for weight loss(ie "scans")
have been unrevealing. He reports an increase in appetite in the
past month. He admits today for heparin bridge with plans for OR
in the am for MV repair vs replacement / ? AVR / ? MAZE.
Past Medical History:
Mitral Valve Prolapse/Mitral Regurgitation
Atrial Fibrillation
Hypothyroidism
Alcoholism - sober for last three months, normal LFTs
Anxiety/Depression
Abdominal versus Bilateral Inguinal Hernias
Chronic Back Pain
Social History:
Race:Causcasian
Last Dental Exam: 1 month ago
Lives with: Alone
Occupation: Disabled(back injury [**2144**])
Tobacco: Never
ETOH:History of Alcoholism/Binge drinking, quit 3 months ago
Family History:
non-contributory
Physical Exam:
Pulse: Resp:12 O2 sat: 96% RA
B/P Right: 94/60 Left:
Height: 5'5" Weight:154 lbs
General:AAO x 3 in NAD
Skin: Dry [x] intact [x] Yellow plaques on nose
HEENT: PERRLA [x] EOMI [x] left eyelid droop
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur IV/VI holosystolic murmur
best heard at apex
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] + bilateral inguinal hernias
Extremities: Warm [x], well-perfused [x] 1+ bilateral Lower
extremity edema Varicosities: None [x]
Neuro: Grossly intact intentional tremor
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 2+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2181-2-23**] Echo: Pre-bypass: The left atrium is markedly dilated.
No mass/thrombus is seen in the left atrium or left atrial
appendage. The right atrium is moderately dilated. A patent
foramen ovale is present. Left ventricular wall thicknesses are
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are myxomatous. An eccentric, anteriorly directed jet
of Severe (4+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
[**2181-2-18**] 05:23PM BLOOD WBC-6.3 RBC-4.29* Hgb-14.1 Hct-42.1
MCV-98 MCH-32.9* MCHC-33.5 RDW-15.2 Plt Ct-225
[**2181-3-1**] 06:15AM BLOOD WBC-7.2 RBC-3.37* Hgb-10.7* Hct-32.1*
MCV-95 MCH-31.6 MCHC-33.3 RDW-16.7* Plt Ct-267
[**2181-2-18**] 05:23PM BLOOD PT-19.2* PTT-32.4 INR(PT)-1.8*
[**2181-3-1**] 06:15AM BLOOD PT-13.2 PTT-26.6 INR(PT)-1.1
[**2181-2-18**] 05:23PM BLOOD Glucose-124* UreaN-17 Creat-1.1 Na-138
K-3.6 Cl-96 HCO3-31 AnGap-15
[**2181-3-1**] 06:15AM BLOOD Glucose-85 UreaN-12 Creat-0.9 Na-140
K-4.5 Cl-105 HCO3-26 AnGap-14
[**2181-2-23**] 08:50PM BLOOD ALT-14 AST-44* LD(LDH)-339* AlkPhos-44
TotBili-0.8
[**2181-2-18**] 05:23PM BLOOD %HbA1c-5.5
Brief Hospital Course:
Mr. [**Known lastname 12130**] was admitted to the [**Hospital1 18**] on [**2181-2-18**] for surgical
management of his mitral valve disease. Heparin was started as a
bridge to surgery. He was worked-up in the usual preoperative
manner. As his INR was quite slow to reach a safe range for
surgery, his surgery was delayed a few days. On [**2181-2-23**], Mr.
[**Known lastname 12130**] was taken to the operating room where he underwent a
mitral valve repair with a triangular
resection of the middle scallop of the posterior leaflet (P2)
and mitral valve annuloplasty with a 32-mm St. [**Hospital 923**] Medical
saddle ring. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring. He did require Inotropes post-op for hemodynamic
support and were weaned off on post-op day 3. He did receive a
blood transfusion for hematocrit 26%. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
Chest tubes and epicardial pacing wires were removed per
protocol. On post-op day four he was transferred to the
telemetry floor for further care. Physical therapy was
consulted for assistance with post-op strength and mobility. By
POD 5 the patient was found suitable for transfer to rehab. By
this time the wound was healing, pain was controlled with oral
analgesics, and the patient was ambulating with supervision.
Medications on Admission:
Furosemide 40 mg po daily
Lopressor 12.5mg po daily
Levothyroxine 50mcg po daily
Zyprexa 2.5mg po daily
Sertraline 100mg po daily
Digoxin 0.25 mg po daily
Coumadin 5mg po daily - last dose [**2181-2-13**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) as needed for afib.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for afib: 200mg 2x/day x 1 week, then 200mg
daily until further instructed. Tablet(s)
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose
to change daily for goal INR [**3-14**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center
Discharge Diagnosis:
Mitral Valve Prolapse/Mitral Regurgitation
Atrial Fibrillation
Hypothyroidism
Alcoholism - sober for last three months, normal LFTs
Anxiety/Depression
Abdominal versus Bilateral Inguinal Hernias
Chronic Back Pain
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **] in [**2-10**] weeks
Cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-10**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2181-3-1**]
|
[
"427.31",
"V58.61",
"300.4",
"338.29",
"305.00",
"724.5",
"458.29",
"429.3",
"424.0",
"244.9",
"550.92",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
6984, 7038
|
4196, 5594
|
340, 546
|
7294, 7389
|
2668, 4173
|
7929, 8353
|
1822, 1840
|
5849, 6961
|
7059, 7273
|
5620, 5826
|
7413, 7906
|
1855, 2649
|
281, 302
|
574, 1368
|
1390, 1604
|
1620, 1806
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,948
| 192,075
|
35157
|
Discharge summary
|
report
|
Admission Date: [**2147-10-16**] Discharge Date: [**2147-11-2**]
Date of Birth: [**2074-4-16**] Sex: M
Service: SURGERY
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
painless jaundice
Major Surgical or Invasive Procedure:
[**10-18**]: PTC
[**10-25**]: ex-lap, liver bx, gastrojejunostomy & cholejejunostomy
History of Present Illness:
73M with h/o a-fib, MR, presenting for evaluation with painless
jaundice. He and his family first noticed the yellowing of his
skin a week prior to admission. He has also noted light colored
diarrhea. He denies abd pain. No f/c. He was seen by his PCP who
did lab work-up and referred for outpatient GI consult with
[**Last Name (LF) 80248**], [**First Name3 (LF) 1158**]. The patient was then admitted for ERCP. ERCP
showed "malignant intrinsic stenosis was found in the distal
bulb" and the scope was not able to traverse the lesion. Dr. [**Name (NI) 30888**] service was contact[**Name (NI) **] for consultation by the GI team.
Past Medical History:
afib
dm2
mitral regurg
CAD: by report from family, cath showed 50% stenosis in the
"main vessel"
GERRD
Social History:
quit smoking, occasional etoh
Family History:
mother lived to 95, father lived to 60s
Physical Exam:
VS: Temp: 99.5 BP: 112/72 HR: 76 RR: 16 O2sat: 99RA
.
Gen: In NAD.
HEENT: perrl, scleral icterus
Necck: Supple, no LAD, no JVP elevation.
Lungs: CTA bilaterally, no wheezes, rales, rhonchi. Normal
respiratory effort.
CV: RRR, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS, no HSM.
Extremities: warm and well perfused, no cyanosis, clubbing,
edema.
Neurological: alert and oriented X 3
Skin: No rashes or ulcers.
Psychiatric: Appropriate.
Pertinent Results:
[**2147-10-16**] 10:35AM GLUCOSE-164* UREA N-12 CREAT-0.7 SODIUM-136
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
[**2147-10-16**] 10:35AM estGFR-Using this
[**2147-10-16**] 10:35AM ALT(SGPT)-127* AST(SGOT)-120* ALK PHOS-622*
AMYLASE-78 TOT BILI-12.0* DIR BILI-9.4* INDIR BIL-2.6
[**2147-10-16**] 10:35AM LIPASE-171*
[**2147-10-16**] 10:35AM ALBUMIN-3.3*
[**2147-10-16**] 10:35AM WBC-8.6 RBC-4.27* HGB-12.7* HCT-36.1* MCV-85
MCH-29.7 MCHC-35.1* RDW-15.9*
[**2147-10-16**] 10:35AM NEUTS-70.4* LYMPHS-16.2* MONOS-7.7 EOS-5.1*
BASOS-0.6
[**2147-10-16**] 10:35AM PLT COUNT-279
[**2147-10-16**] 10:35AM PT-12.4 PTT-22.5 INR(PT)-1.0
.
SPECIMEN SUBMITTED: DUODENUM MASS BX, 1 JAR.
Procedure date Tissue received Report Date Diagnosed
by
[**2147-10-16**] [**2147-10-17**] [**2147-10-18**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/ttl
DIAGNOSIS:
Duodenal mass, biopsy:
1. Chronic active duodenitis with Brunner's gland hyperplasia.
2. No carcinoma seen.
.
[**2147-10-16**] ERCP
Procedures: Cold forceps biopsies were performed for histology
at the Duodenum bulb mass.
Impression: A malignant intrinsic stenosis was found in the
distal bulb. The scope did not traverse the lesion. The scope
did not traverse the lesion.
A medium size hiatal hernia was seen.
.
CT [**2147-10-16**]
IMPRESSION:
1. 2-cm mass within the second part of duodenum, most likely
adenocarcinoma with associated common bile duct, extrahepatic,
and intrahepatic biliary duct dilatation.
2. Multiple liver lesions concerning for metastasis.
3. Epiploic appendagitis of uncertain chronicity at the hepatic
flexure.
.
[**2147-10-18**] PTC
1. PTC demonstrating markedly dilated intra- and extra-hepatic
biliary ductal system with segmental stricture seen at the level
of the distal common bile duct/ampulla.
2. Placement of 8 French internal/external biliary drainage
catheter.
.
[**2147-10-28**] 03:57AM BLOOD WBC-13.5* RBC-2.96* Hgb-8.4* Hct-26.1*
MCV-88 MCH-28.4 MCHC-32.3 RDW-15.3 Plt Ct-321
[**2147-10-28**] 12:50PM BLOOD WBC-13.5* RBC-2.92* Hgb-8.7* Hct-25.8*
MCV-88 MCH-29.8 MCHC-33.9 RDW-15.9* Plt Ct-338
[**2147-11-2**] 05:00AM BLOOD WBC-11.7* RBC-3.22* Hgb-9.3* Hct-27.7*
MCV-86 MCH-29.0 MCHC-33.7 RDW-16.2* Plt Ct-462*
[**2147-11-2**] 05:00AM BLOOD PT-14.0* PTT-28.7 INR(PT)-1.2*
[**2147-11-1**] 05:50AM BLOOD PT-14.6* PTT-30.6 INR(PT)-1.3*
[**2147-11-1**] 05:50AM BLOOD PT-14.6* PTT-30.6 INR(PT)-1.3*
[**2147-11-2**] 05:00AM BLOOD Glucose-110* UreaN-21* Creat-0.9 Na-136
K-4.4 Cl-105 HCO3-23 AnGap-12
[**2147-11-1**] 05:50AM BLOOD Glucose-117* UreaN-20 Creat-0.7 Na-139
K-4.2 Cl-107 HCO3-22 AnGap-14
[**2147-10-23**] 04:22AM BLOOD ALT-56* AST-81* AlkPhos-415* TotBili-4.9*
[**2147-10-20**] 06:10AM BLOOD ALT-64* AST-65* AlkPhos-454* TotBili-6.9*
[**2147-10-29**] 02:33PM BLOOD CK(CPK)-345*
[**2147-10-20**] 06:10AM BLOOD Lipase-130*
[**2147-10-19**] 07:40AM BLOOD Lipase-128*
[**2147-10-17**] 05:55AM BLOOD Lipase-215*
[**2147-10-31**] 06:42AM BLOOD calTIBC-148* Ferritn-671* TRF-114*
[**2147-10-23**] 04:22AM BLOOD calTIBC-200* Ferritn-1463* TRF-154*
[**2147-10-31**] 06:42AM BLOOD Triglyc-200* HDL-15 CHOL/HD-8.0
LDLcalc-65
Brief Hospital Course:
[**10-16**]: Pt admitted with painless jaundice; ERCP found severe
malignant intrinsic stenosis
[**10-17**]: Transferred to [**Hospital Ward Name 121**] 9
[**10-18**]: percutaneous transhepatic cholangiography and drain
placement;
[**10-19**]: placed PICC and started on TPN
[**10-20**]: pt with witnessed fall, hit right forehead on floor, no
LOC, no SOB. normal neurologic exam
[**10-25**]: pt again had unwittnessed fall, no LOC, somewhat confused
states was "investigating a murder"; CT normal, no intracranial
bleed; it was decided that patient was appropriate to go to the
OR with improved mental status. PICC site with some mild
erythema, tip cultured (subsequently negative).
-->also underwent gastrojejunostomy, cholejejunostomy, liver
biopsy, CVL placement; findings were significant for multiple
liver nodules and omental mass c/w metastatic dz, liver frozen
path: adeno-carcinoma
[**10-26**]: pt continued on rate control for AFib Pt admitted to ICU
post op for HR monitoring, diagnosed with suspected pneumonia
and started on levaquin though afebrile and no issues with
secretions
[**10-27**]: pt out of ICU
[**10-28**]: continued [**Last Name (un) **]/NGT, still with slight confusion on POD 3
[**10-29**]: NGT d/c'ed, slowly began advancing diet
[**10-30**]: pt with resolving delerium/sedation, advanced to clears
[**10-31**]:pt began on normal diet, tolerated well, TPN weaned to [**12-21**]
[**11-1**]: weaned off TPN, levaquin stopped, doing extraordinarily
well clinically, CVL removed
OVERALL:
GI: ultimately had successful return to bowel function by end of
stay, weaned off TPN and tolerating food well
Heme: coumadin began post-op, INR still 1.3 at discharge, spoke
with PMD, will f/u as outpatient with blood draws, will d/c on
5mg coumadin daily
CV: rate controlled AFib throughout stay
ID: treated with 7 day course of levaquin for presumed PNA,
remained afebrile
Neuro: had issues with transient delerium likely [**1-21**] complicated
operative course, resolved at discharge
Pulmonary: no issues
Endo: remained on ISS and metformin for tight glucose control
PPx: remained on PPI and SQH while in house
Medications on Admission:
dilt 240 SR qd
metformin 500mg SR qd
omeprazole 20'
coumadin 5mg qd
asa 81
Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for
1 weeks.
[**Month/Day (2) **]:*7 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) for 2 weeks: refill through your primary care
physician.
[**Name Initial (NameIs) **]:*14 Tablet(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
[**Name Initial (NameIs) **]:*30 Tablet(s)* Refills:*0*
4. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Metastatic Adenocarcinoma of Pancreas/Liver
Discharge Condition:
Stable, with PTC drain
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
* Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
* Avoid driving or operating heavy machinery while taking pain
meds.
Incision Care:
-Avoid swimming and baths until your follow-up appointment.
-It is OK to shower and wash. pat incision dry. No lotions,
powders etc.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] ([**Telephone/Fax (1) 14347**] in [**1-22**] weeks.
Staples out at 14 days post op
It is imperative that you follow up with your primary care
doctor for an INR level on [**11-4**], and then schedule an
appointment next week to dose your coumadin.
Completed by:[**2147-11-2**]
|
[
"530.81",
"553.3",
"537.0",
"197.4",
"293.0",
"396.3",
"V15.88",
"414.01",
"427.31",
"576.2",
"197.7",
"250.00",
"157.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"44.39",
"51.32",
"38.91",
"45.14",
"87.51",
"50.12",
"51.87",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
7795, 7856
|
4942, 7082
|
295, 382
|
7944, 7969
|
1769, 4919
|
9411, 9745
|
1231, 1272
|
7207, 7772
|
7877, 7923
|
7108, 7184
|
7993, 9130
|
9145, 9388
|
1287, 1750
|
238, 257
|
410, 1042
|
1064, 1168
|
1184, 1215
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,298
| 186,853
|
7806
|
Discharge summary
|
report
|
Admission Date: [**2123-6-11**] Discharge Date: [**2123-6-14**]
Date of Birth: [**2047-9-27**] Sex: F
Service: SURGERY
Allergies:
Tape [**12-14**]"X10YD / Morphine
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Claudication
Major Surgical or Invasive Procedure:
[**2123-6-11**] Iliac artery stent grafts x2.
History of Present Illness:
75 year old female with a history of coronary artery disease
status post RCA stenting in [**2116**] and cath in [**1-24**] with occluded
LAD and minimal RCA ISR, presumed infarct related cardiomyopathy
with recent PMIBI showing LVEF of 30% and fixed anterior defect
presents for bilateral lower extremity angiography and stenting
because of cluadication and postive ABIs.
Past Medical History:
-Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis
Social History:
- Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits.
Family History:
No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.
Physical Exam:
Pt expired.
Pertinent Results:
[**2123-6-11**] C. cath INTERVENTIONAL COMMENTS:
Initial angiography demonstrated right common and external iliac
artery
stenosis that on careful hemodynamic assessment (slow pullback
of MPA-1
catheter from common femoral artery to distal aorta) revealed a
significant 40 mmHg peak-to-peak gradient at this location with
normalization of the pressure to the central aorta beyond. After
discussion and review of the images with Vascular Surgery, Dr.
[**Last Name (STitle) 3407**],
we planned to treat this inflow disease with PTA and stenting
followed
by inpatient admission for further planning of lower extremity
revascularization with surgical bypass grafting.
Prior to the intervention, heparin was given prophylactically
and a
therapeutic ACT was confirmed. The short 5F right brachial
artery sheath
was exchanged over a wire for a 90cm long 5F Shuttle Sheath
placed in
the proximal right common iliac artery immediately prior to the
lesion.
The lesion was crossed easily with a V-18 wire and then
pre-dilated with
a 6.0x40mm Submarine Plus balloon for prolonged inflations at
low
pressure. A 7.0x60mm Zilver self-expanding stent was then
deployed and
the lesion was post-dilated with a 7.0x40mm Submarine Plus
balloon at 10
atm for 60 sec and then again at 10 atm for 70 sec. Repeat
pullback
across the lesion with a 5F MPA-1 catheter revealed improved
peak-to-peak pressure gradient of 20 mmHg, with interim
angiography
demonstrating a residual 30% stenosis in the mid-stent.
Following a final post-dilatation inflation with a 7.0x40mm
Submarine
Plus balloon at 10 atm for 40 sec to treat the mid-stent
residual
stenosis, angiography demonstrated active contrast extravasation
(perforation) of the external and common iliac artery within the
stented
segment. The patient rapidly became hypotensive with SBP 70s and
was
given wide-open IV fluids and started on dopamine IV and
neosynepherine
IV vasopressor support with improvement of SBP 90s. A 7.0x80mm
Submarine
Plus balloon was advanced across the perforation site and
inflated with
successful tamponade of the bleeding evidenced by resolution of
contrast
extravasation on angiography. Protamine was administered for
reversal of
heparinzation given active bleeding. The patient was intubated
by
anesthesia for airway protection. 7.5F right internal jugular
and 7F
right femoral venous access sheaths were inserted and 3 units
packed
RBCs were rapidly administered with eventual weaning off off
dopamine
and neosynepherine and stabilization of SBP 110-120s.
For definitive treatment of the perforation, retrograde right
femoral
arterial access was obtained with micropuncture technique under
fluoroscopic guidance and a 7F sheath was inserted. A Magic
Torque wire
was advanced across the perforation site to the ascending aorta
and
after deflation and withdrawal of the antegrade 7.0x80mm
Submarine Plus
balloon a 7.0x59mm ICAST covered stent was deployed across the
right
external and common iliac artery. Interim angiography
demonstrated a
small area of dissection/extravastion at the proximal end of the
covered
stent, and therefore an additional overlapping 7.0x38mm ICAST
covered
stent was deployed proximally. Final angiography demonstrated no
residual perforation, no angiographically apparent dissection,
no
residual stenosis in the stented segment, and normal flow.
Right heart catheterization was then performed via the RIJ with
a 7.5F
Swan-Ganz VIP catheter notable for normal right and left heart
filling
pressures with RVEDP 9 mmHg and PCWP 14 mmHg (see above for
complete
hemodynamics), and was then sutured in place for ongoing
hemodynamic
monitoring with the catheter tip located in the central
pulmonary
artery. The right brachial and right femoral arterial sheaths
were
removed manually with adequate hemostasis. The patient remained
hemodynamically stable off vasopressors in the catheterization
lab and
was transferred to the CVICU for further care.
[**2123-6-13**] CXR
FINDINGS: Interval extubation and removal of nasogastric tube.
Slight
advancement of Swan-Ganz catheter, now in the right main
pulmonary artery. Cardiac silhouette remains enlarged, and is
accompanied by new pulmonary vascular congestion and bilateral
dependent alveolar opacities. Bilateral small-to-moderate
pleural effusions are also new.
IMPRESSION:
1. Development of bilateral lower lobe airspace opacities,
which may reflect dependent pulmonary edema. Coexisting
aspiration is an additional
consideration given the clinical concern for aspiration event.
2. New bilateral pleural effusions.
[**2123-6-14**] 04:05AM BLOOD WBC-13.0* RBC-3.54* Hgb-10.8* Hct-33.0*
MCV-93 MCH-30.5 MCHC-32.8 RDW-15.7* Plt Ct-121*
[**2123-6-11**] 03:39PM BLOOD Neuts-81.8* Lymphs-14.4* Monos-3.2
Eos-0.4 Baso-0.2
[**2123-6-14**] 04:05AM BLOOD Plt Ct-121*
[**2123-6-14**] 04:05AM BLOOD Glucose-102* UreaN-13 Creat-0.8 Na-149*
K-4.3 Cl-115* HCO3-20* AnGap-18
[**2123-6-14**] 04:05AM BLOOD ALT-58* AST-112* LD(LDH)-307*
AlkPhos-256* Amylase-25 TotBili-1.2
[**2123-6-14**] 04:05AM BLOOD Lipase-9
[**2123-6-12**] 08:41AM BLOOD CK-MB-10 MB Indx-2.7 cTropnT-0.07*
[**2123-6-14**] 04:05AM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.4 Mg-2.6
[**2123-6-13**] 12:15AM BLOOD Type-CENTRAL VE pO2-57* pCO2-41 pH-7.23*
calTCO2-18* Base XS--9
[**2123-6-12**] 11:11PM BLOOD Glucose-71 Lactate-1.4 K-3.5
[**2123-6-12**] 11:11PM BLOOD freeCa-1.17
Brief Hospital Course:
Pt was admitted for the proposed procedure through the
cardiology service. During the procedure of stenting her right
external iliac the vessel ruptured. Vascualr surgery was
consulted during the case. She underwent s/p stent graft repair
with 2X covered stents. During the procedure she had a transient
episode of hypotension
that was treated with neosynephrine in the cath lab initially
but resolved prior to transfer to the CVICU. Cardiology was
consulted for their input on her coronary disease and
infarct-related cardiomyopathy in the post-procedural setting.
Her family was contact[**Name (NI) **] and her situation discussed.
She was diuresed overnight and the plan was for extubation in
the morning. She self extubated overnight on the [**2123-6-12**] ->
[**2123-6-13**]. She was made DNR DNI and was supported. She expired
the following afternoon with her family at her side.
Medications on Admission:
ASA, plavix, metoprolol 25', atorvastatin 80', losartan 25',
Lasix 20', Amlodipine 5 mg', prednisone 5', Keppra 750'',
celecoxib 100', benzonatate 100', omeprazole 20', Brimonidine
(0.2 % 1 in L eye'''), timolol maleate (0.255 each eye'), B12 IM
(1x/mo), Vit D 400U'
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Right iliac artery rupture
Heart Failure
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2123-6-14**]
|
[
"492.8",
"345.90",
"V49.86",
"443.0",
"414.8",
"281.0",
"998.2",
"412",
"707.15",
"401.9",
"440.23",
"428.23",
"714.0",
"440.31",
"285.1",
"288.60",
"276.2",
"428.0",
"424.0",
"276.52",
"V58.65",
"440.0",
"416.8",
"458.29",
"V45.82",
"414.01",
"424.2",
"443.22",
"998.11",
"E870.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.90",
"88.42",
"39.50",
"88.48",
"00.41",
"00.47",
"37.21"
] |
icd9pcs
|
[
[
[]
]
] |
8383, 8392
|
7140, 8036
|
306, 355
|
8477, 8487
|
1748, 7117
|
8540, 8576
|
1594, 1701
|
8354, 8360
|
8413, 8456
|
8063, 8331
|
8511, 8517
|
1716, 1729
|
254, 268
|
383, 756
|
778, 1458
|
1474, 1578
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,429
| 110,780
|
9656+56052
|
Discharge summary
|
report+addendum
|
Admission Date: [**2201-2-12**] Discharge Date: [**2201-2-16**]
Date of Birth: [**2126-7-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Mevacor / Lipitor / Tricor / Zocor / Pravachol / statins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pressure and dyspnea
Major Surgical or Invasive Procedure:
Coronary Artery Bypass x 4 (LIMA-LAD, SVG-DIAG, SVG-OM, SVG-PDA)
[**2201-2-12**]
History of Present Illness:
This is a 74 year old gentleman with
known coronary artery disease status post PTCA and stenting in
the past who presented to his cardiologist with increasing
episodes of exertional chest pressure and dyspnea. He underwent
a
stress test which when compared to his previous study in [**2199-8-16**] showed a decreased ejection fraction, wall abnormalities
which were more pronounced and new, more extensive inferior and
anterior ischemia. He underwent a cardiac cath on [**2201-1-1**] which
showed severe three vessel coronary artery disease and was thus
referred for surgical revascularization.
Past Medical History:
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- Prior asbestos exposure
- Hx of prostate cancer
- Chronic Venous Stasis with some varicose veins
Past Surgical History:
- LAD stenting [**3-/2186**]/RCA stenting in 12/97/PLV stenting in [**5-19**].
- Radical prostatectomy c/b bowel injury requiring diverting
colostomy which was eventually reversed
- Umbilical Hernia Repair
Social History:
Lives: Alone
Occupation: Marine Distributor
Cigarettes: Denies
ETOH: < 1 drink/week [] [**12-23**] drinks/week [x] >8 drinks/week []
Illicit drug use: Denies
Family History:
Brother with PTCA in his 50's. Father also
underwent CABG in his 60's
Physical Exam:
Pulse: 88 Resp: 16 O2 sat: 100% room air
B/P Right: 185/100 Left: 178/100
General: WDWN male in no acute distress. Appears younger than
stated age of 74. Very anxious and appeared stressed.
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x] - multiple, well healed scars
Extremities: warm, chronic venous statis changes noted
Edema: Trace
Varicosities: anterior varicosities noted. right leg appeared to
have more varicosed areas compared to left. left greater
saphenous appeared suitable from ankle to groin. right greater
saphenous appeared suitable from just below knee to groin.
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2 ** right femoral bruit noted **
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Pertinent Results:
[**2201-2-12**] Intra-op Echo:
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results at
time of surgery.
POST-BYPASS: The patient is atrial paced, systolic function is
unchanged, no new regional wall motion abnormalities. No new
valvular abnormalities. No sign of ascending aorta dissection.
[**2201-2-16**] 04:45AM BLOOD WBC-10.8 RBC-3.30* Hgb-10.1* Hct-31.6*
MCV-96 MCH-30.6 MCHC-31.9 RDW-13.3 Plt Ct-193
[**2201-2-16**] 04:45AM BLOOD Plt Ct-193
[**2201-2-16**] 04:45AM BLOOD Plt Ct-193
[**2201-2-16**] 04:45AM BLOOD PT-13.4* INR(PT)-1.2*
[**2201-2-15**] 05:51AM BLOOD Plt Ct-171
[**2201-2-15**] 05:51AM BLOOD PT-12.7* INR(PT)-1.2*
[**2201-2-16**] 04:45AM BLOOD Glucose-122* UreaN-40* Creat-1.3* Na-140
K-4.0 Cl-106 HCO3-27 AnGap-11
[**2201-2-16**] 04:45AM BLOOD Mg-2.5
Brief Hospital Course:
The patient was brought to the Operating Room on [**2-12**]/12where
the patient underwent CABG x 4 with Dr. [**Last Name (STitle) **]. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery. He
had several bouts of atrial fibrillation. He converted to sinus
rhythm with amiodarone and titration of beta blocker. He was
started on coumadin and Coumadin follow up was arranged with Dr.
[**Last Name (STitle) 7389**]. Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD #4 the patient was ambulating freely, he was
hemodynamically stable in sinus rhythm, his wounds were healing
and pain was controlled with oral analgesics. The patient was
discharged in good condition with appropriate follow up
instructions. His creatinine was elevated from baseline at
discharge will need to be monitored over the next few days.
Medications on Admission:
Medications - Prescription
CHOLESTYRAMINE-ASPARTAME [CHOLESTYRAMINE LIGHT] - (Prescribed
by
Other Provider) - 4 gram Packet - 4 gms by mouth twice a day
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - (Prescribed by
Other Provider) - 320 mg-25 mg [**Last Name (STitle) 8426**] - 1 [**Last Name (STitle) 8426**](s) by mouth
once
a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg [**Last Name (STitle) 8426**],
Delayed
Release (E.C.) - 1 [**Last Name (STitle) 8426**](s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit [**Last Name (STitle) 8426**], Chewable - 1 [**Last Name (STitle) 8426**](s) by mouth once a day
COENZYME Q10 - (Prescribed by Other Provider) - 100 mg Capsule
-
1 Capsule(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider)
-
1,000 mcg [**Last Name (STitle) 8426**] - 1 [**Last Name (STitle) 8426**](s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 0.8 mg [**Last Name (STitle) 8426**] - 1
[**Last Name (STitle) 8426**](s) by mouth once a day
OMEGA 3-DHA-EPA-FISH OIL [OMEGA-3 FISH OIL] - (Prescribed by
Other Provider) - 910 mg (308 mg-448 mg-154 mg)-1,400 mg Capsule
- 1 Capsule(s) by mouth once a day
Discharge Medications:
1. potassium chloride 10 mEq [**Last Name (STitle) 8426**] Extended Release Sig: Two
(2) [**Last Name (STitle) 8426**] Extended Release PO once a day for 7 days.
Disp:*14 [**Last Name (STitle) 8426**] Extended Release(s)* Refills:*0*
2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
PO BID (2 times a day).
Disp:*60 Packet(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. aspirin 81 mg [**Last Name (STitle) 8426**], Delayed Release (E.C.) Sig: One (1)
[**Last Name (STitle) 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 [**Last Name (STitle) 8426**], Delayed Release (E.C.)(s)* Refills:*2*
6. metoprolol tartrate 50 mg [**Last Name (STitle) 8426**] Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 [**Last Name (STitle) 8426**](s)* Refills:*2*
7. warfarin 1 mg [**Last Name (STitle) 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] Once Daily at 4
PM.
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*2*
8. tramadol 50 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*40 [**Last Name (Titles) 8426**](s)* Refills:*0*
9. amiodarone 200 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO BID (2 times
a day): then 200mg po bid x 7days then 200mg po daily until seen
by cardiologist.
Disp:*120 [**Last Name (Titles) 8426**](s)* Refills:*2*
10. Lasix 40 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once a day for 7
days.
Disp:*7 [**Last Name (Titles) 8426**](s)* Refills:*0*
11. Vitamin D3 1,000 unit [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once a
day.
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
12. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
13. cyanocobalamin (vitamin B-12) 1,000 mcg [**Last Name (Titles) 8426**] Sig: One (1)
[**Last Name (Titles) 8426**] PO once a day.
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
14. folic acid 1 mg [**Last Name (Titles) 8426**] Sig: One (1) [**Last Name (Titles) 8426**] PO once a day.
Disp:*30 [**Last Name (Titles) 8426**](s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] [**Location (un) 5087**]
Discharge Diagnosis:
- Coronary artery disease
- Hypertension
- Hyperlipidemia
- Prior asbestos exposure
- Hx of prostate cancer
- Chronic Venous Stasis with some varicose veins
Past Surgical History:
- LAD stenting [**3-/2186**]/RCA stenting in 12/97/PLV stenting in [**5-19**].
- Radical prostatectomy c/b bowel injury requiring diverting
colostomy which was eventually reversed
- Umbilical Hernia Repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
1+ edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2201-2-24**] at
10:30 AM
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2201-3-25**] at 1:30p
PCP/Cardiologist Dr. [**Last Name (STitle) 7389**], [**Telephone/Fax (1) 14525**] on [**2201-3-4**] at 11:15a
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for AFib
Goal INR 2-2.5
First draw day after discharge [**2201-2-17**] - please check INR and
crea
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 7389**]
Results to phone [**Telephone/Fax (1) 14525**]
Completed by:[**2201-2-16**] Name: [**Known lastname 5668**],[**Known firstname 33**] Unit No: [**Numeric Identifier 5669**]
Admission Date: [**2201-2-12**] Discharge Date: [**2201-2-16**]
Date of Birth: [**2126-7-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Mevacor / Lipitor / Tricor / Zocor / Pravachol / statins
Attending:[**First Name3 (LF) 741**]
Addendum:
Patient with mild erythema and minimal turbulent drainage from
upper sternal pole with pressure. Betadine wipes [**Hospital1 **] to sternal
incision, Kelfex 500 mg QID x 7 days and wound check this Thurs
[**2201-2-19**]- office to call patient with time.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] [**Location (un) 5670**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2201-2-16**]
|
[
"V10.46",
"459.81",
"414.01",
"401.9",
"427.31",
"V45.82",
"413.9",
"V15.84",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.13"
] |
icd9pcs
|
[
[
[]
]
] |
12560, 12755
|
4453, 5890
|
361, 444
|
10089, 10254
|
2748, 4430
|
11042, 12537
|
1671, 1742
|
7192, 9564
|
9680, 9837
|
5916, 7169
|
10278, 11019
|
9860, 10068
|
1757, 2729
|
283, 323
|
472, 1069
|
1091, 1248
|
1495, 1655
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,624
| 156,812
|
43930
|
Discharge summary
|
report
|
Admission Date: [**2132-8-16**] Discharge Date: [**2132-8-20**]
Date of Birth: [**2063-10-15**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Penicillins / Tetracyclines / Erythromycin Base /
Ciprofloxacin
Attending:[**First Name3 (LF) 13024**]
Chief Complaint:
DYSPNEA/HYPOTENSION
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 13469**] is a 68 year old gentleman with DM 2, seizure
disorder, dCHF, HTN, and neuropathy discharged yesterday after
completing an 11 day course of vancomycin for a LLL MRSA
pneumonia admitted for hypotension. The patient reports that
after discharge yesterday, he spent the night at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**]
shelter. This morning, he reports feeling as if he was
"falling," that he "couldn't control his steps," and that his
"body short-circuited." Then then saw an EMS at [**Location (un) 86**] Common,
at which point he was noted to have a SBP 70s and was
transported to [**Hospital1 18**].
In the [**Hospital1 18**] ED, VS 98.4 80/47 64 20 96%RA. He received 500 cc -
3L IVF without improvement in BP, and so a RIJ CVL was placed
and levophed was started. He was then admitted to the MICU for
further management. Labs were notable for an acetaminophen level
of 14, creatinine of 3.2 from 1.1 yesterday, and a lactate of
2.4 decreased to 1.6 after 3L IVF.
.
Currently, he states that his shortness of breath is stable. He
also endorses an increased cough since discharge that is
non-productive. Denies CP, f/c/s, n/v/d, abd pain, HA,
palpitations. States that his disequilibirum symptoms have since
resolved.
.
ROS: Also endorses orthostasis and decreased UOP over the past
day. As above, otherwise negative.
Past Medical History:
1. Seizure history - describes as "[**Doctor Last Name 11332**] mal" but was previously
described as "tonic-clonic" with bilateral arm shaking, no LOC.
Was on Trileptal in the past, but was weaned off due to
associated hyponatremia, now on Keppra. Followed by Dr. [**First Name (STitle) 3322**]
[**Name (STitle) **] (EEG negative 2/[**2132**]).
2. Headaches - taken multiple narcotics in the past to
treat this, in addition to advil and tylenol. It was described
in
prior notes as starting on the left side of his head and
radiating anteriorly and down his back. He also has had
documented left face pain.
3. Type II DM
4. Peripheral neuropathy
5. Hypertension
6. Hypercholesterolemia
7. Diastolic Dysfunction (EF 60-70% on recent echo with LVH)
8. GERD
9. Depression/Anxiety
10. Lumbar spinal stenosis w/ history C3/C7 fractures
11. Degenerative joint disease
12. Neurogenic bladder
13. s/p left cataract surgery
[**37**]. Vitamin B12 deficiency
15. Atypical CP (last MIBI negative [**3-10**])
16. Hyponatremia (baseline 128-131)
17. h/o multiple falls due to multifactorial gait ataxia, also
followed by Dr. [**First Name (STitle) 3322**] [**Name (STitle) **]
18. 8-mm thecal mass, stable over several years, consistent with
nerve sheath tumor.
19. Likely prior left temporal infarct (per atrophy on head MRI)
Social History:
Homeless, retired Operating Room nurse, Buddhist monk, sister
living in
[**Name (NI) **] as only family but who has declined to take him in.
Tobacco: former smoker, ~45 pack year history (quit 30 years
ago)
.
Also, per records:
Pt has been living on the street for 3-4 months. Was engaged to
a woman many years ago but broke it off. He states he had many
relationships, and used to be bisexual. Now he is "celibate"
since becoming a priest and is not in any relationship.
Graduated from high school. College graduate. Worked on Masters.
Attended nursing school. Buddhist priest x 25 years. Was working
to counsel AIDS patients prior to becoming homeless (x 10
years). No social supports in [**Location (un) 86**]. All of his friends have
passed away.
.
Pt has a history of sexual abuse by his father's brother at age
[**6-8**]. Never told anybody, no treatment. Was also physically
abused by his father growing up.
Family History:
Mother died of esophageal cancer, ?EtOH abuse and depression.
Father died suddenly of heart attack.
Multiple family members with CAD including father, sister [**Name (NI) **] at
58 yo), all 4 grandparents
Type 2 DM (paternal grandfather)
Esophageal cancer (mother)
Physical Exam:
VS: 96 58 116/95 15 99%RA.
Gen: Age appropriate male in NAD
HEENT: Perrl, [**Name (NI) **], sclerae anicteric. MMM, OP clear without
lesions, exudate or erythema. Neck supple without LAD
CV: Nl S1+S2, no m/r/g
Pulm: Bibasilar rales (L>R). Decreased BS at left base with
dullness to percussion.
Abd: S/NT/ND +bs
Ext: No c/c/e. 1+ dp/pt bilaterally
Neuro: AOx3, CN II-XII intact, gait not assessed. FTN normal.
Pertinent Results:
Admission Labs:
[**2132-8-15**] 06:07AM WBC-5.6 RBC-4.09* HGB-11.0* HCT-34.6* MCV-85
MCH-27.0 MCHC-31.9 RDW-15.0
[**2132-8-15**] 06:07AM CORTISOL-15.1
[**2132-8-15**] 06:07AM GLUCOSE-65* UREA N-12 CREAT-1.1 SODIUM-145
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-28 ANION GAP-12
[**2132-8-16**] 10:05AM PT-12.4 PTT-24.1 INR(PT)-1.0
Discharge Labs:
[**2132-8-19**] 07:30AM BLOOD WBC-5.0 RBC-4.04* Hgb-11.2* Hct-34.5*
MCV-85 MCH-27.6 MCHC-32.4 RDW-15.7* Plt Ct-252
[**2132-8-19**] 07:30AM BLOOD PT-11.3 PTT-25.8 INR(PT)-0.9
[**2132-8-19**] 07:30AM BLOOD Glucose-77 UreaN-13 Creat-1.0 Na-143
K-4.5 Cl-105 HCO3-32 AnGap-11
[**2132-8-19**] 07:30AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1
[**2132-8-16**] 04:00PM BLOOD VitB12-1100* Folate-11.5
[**2132-8-16**] 04:00PM BLOOD TSH-2.7
[**2132-8-17**] 05:10PM BLOOD Cortsol-23.0*
[**2132-8-17**] 05:10PM BLOOD HIV Ab-NEGATIVE
[**2132-8-16**] 10:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-14.0
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2132-8-16**] 11:25AM BLOOD Lactate-1.6
Imaging:
ECG Sinus rhythm. Voltage criteria for left ventricular
hypertrophy (leads I andaVL). Prolonged Q-T interval. Compared
to the previous tracing of [**8-14**]-09bradycardia is absent and Q-T
interval is slightly prolonged.
Non Contrast Chest CT:
Impression:
- Resolution of the lower lobe consolidation with residual left
lower lobe
linear atelectasis with scarring, bronchiectasis and
bronchiolectasis.
- Soft tissue lobulated nodule in the superior segment of the
right lower lobehas slightly increased in size since the study
in [**2124-10-2**].
A PET- CT is recommended for further evaluation.
- Diffuse triple vessel coronary artery and aortic valve
calcification with
stable hiatus hernia.
Brief Hospital Course:
Assessment and Plan: Mr. [**Known lastname 13469**] is a 68 year old gentleman with
DM 2, seizure disorder, dCHF, HTN, and neuropathy admitted for
Hypotension. Patient was discharged one day prior to admission
after completing an 11 day course of vancomycin for a LLL MRSA
pneumonia.
.
# Hypotension: Patient presented to EMS in [**Location (un) 86**] Common with a
blood pressure of 70/palpable. Unclear etiology. The patient
recently completed an 11 day course of vancomycin for possible
MRSA pneumonia at LLL that radiographically resolved prior to
discharge. During this admission, he remained afebrile without a
leukocytosis, although he does report increased cough without
sputum production. The patient also has a history of diabetic
neuropathy as well as orthostasis, and his intermitent
hypotension without a clear source may suggest autonomic
instability. Also, the patient was unclear as to his metoprolol
dosing, and may have taken excessive anti-hypertensives.
Finally, patient has a seizure disorder and it is unclear if
this added to this hypotension episode, even though a seizure
was not witnessed by anyone and patient has not memory of the
event.
The patient was given over 3 liters of NS in the ED with
minimal response. He was then started on levophed and
transferred to the medical intensive care unit. He received one
dose of vancomycin and meropenem, but this was stopped per
infectious disease recommendations. Extensive labs were drawn;
TSH, B12, Folate, SPEP/UPEP, HIV, UA, UCx, BCx, PPD, cardiac
enzymes were all negative. A repeat chest CT showed a resolved
pneumonia, so unlikely could have contributed to this
hypotensive episode. During hypotensive episode patient had
acute kidney injury with a creatinine peak of 3.2 (baseline
~1)and he also had a lactic acidosis. After fluid resuscitation
and normalization of blood pressure, this resolved.
The patient became normo- to hypertensive was transferred to
the floor. His blood pressure began to rise and his blood
pressure medications were slowly added. Patient was transferred
to a rehab facility upon discharge.
# CT Scan: Patient was noted to have a RLL nodule that has
increased in size since prior CT. Patient will need a PET CT for
further evaluation. This will be deferred to the outpatient.
# CV: Patient with diastolic CHF with LVEF 55-60% on [**2132-8-3**].
Patient was not volume overloaded during admission. Of note, the
patient has baseline chronic chest pain of which he takes
nitroglycerin as needed for chest pain and imdur. Patient was
ruled out for MI. He was continued on aspirin. Metoprolol and
Lisinopril were held during acute episode but restarted once
patient was stable without incident.
# Seizure: Patient had no evidence of seizure activity during
admission. He was continued on home dosage of Keppra.
# DM 2: Stable blood sugars. Patient was continued on his home
NPH dosage a regular insulin sliding scale.
# Depression: Patient was recently changed from duloxetine 30 mg
to citalopram 20 mg. Patient would like to be transitioned back
to duloxetine as he felt better on this medication. Further
management of this will be deferred to the outpatient. Patient
was discharged on citalopram.
# Chronic Pain: Patient has chronic back/neck/head pain
secondary to traumatic injury years ago. Patient also complains
of neuropathic pain in feet secondary to diabetes. Patient's
percocet was discontinued as patient had an elevated
acetaminophen level on admission. He was continued on Oxycodone
10 mg PO Q4H:PRN and oxycontin 20 mg [**Hospital1 **]. He was discharged on
oxycodone only. Further management of pain will be deferred to
the outpatient PCP.
[**Name Initial (NameIs) **] gabapentin was held during his acute renal failure.
Once this resolved, he was started back on this medication upon
discharge.
# Hypertension: Blood pressure increased through course of
admission. Metoprolol, lisinopril, and a lower dose of imdur (30
mg) were restarted. Amlodipine 5 mg daily was also held.
Patient tolerated well. Further management of this will be
deferred in the outpatient.
# Hyperlipidemia: Patient continued simvistatin 80 mg
# Neurogenic Bladder: Stable, Patient continued Oxybutynin 5 mg
PO BID.
# GERD: Continued on pantoprazole
Medications on Admission:
Colace 100 mg po bid
Keppra 1000 mg po bid
Metoprolol 12.5 mg po bid
ASA 81 mg daily
Oxybutynin 5 mg po bid
Trazodone 100 mg po qhs
Citalopram 20 mg daily
Isosorbide mononitrate SR 60 mg daily
Cyanocobalamin 100 mc daily
Amlodipine 5 mg daily
Percocet 5-325 mg 1-2 tablets Q4H prn
Gabapentin 1200 mg po bid
Pantoprazole 40 mg daily
NTG SL prn
Simvastatin 80 mg daily
Lisinopril 10 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for Systolic blood pressure < 100 or HR < 60.
8. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
13. Gabapentin 600 mg Tablet Sig: Two (2) Tablet PO twice a day.
14. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for Pain.
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous qAM (every morning).
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: [**6-10**]
Units Subcutaneous qPM (every evening).
17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) **] [**Doctor First Name **] - [**Location (un) 4047**]
Discharge Diagnosis:
Primary:
Hypotension
h/o MRSA pneumonia
Secondary:
Diabetes Type 2
Seizure disorder
Diastolic Heart Failure
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because you had very low blood pressure. You
were given fluids, but your blood pressure did not increase very
much. You were started on medications to increase your blood
pressure and you were monitored in the intensive care unit.
It was not clear why your blood pressure was low. You may have
had a seizure, may have had too much blood pressure medication,
or your pneumonia may have not fully resolved.
It was felt that your pneumonia resolved per CT scan, absence
of fever, and breathing with good oxygen saturation. In case it
was your blood pressure, we decreased some of your blood
pressure medications. It was not clear if you had a seizure
before you came to the hospital, but you did not have a seizure
in the hospital and were maintained on Keppra.
You blood pressure stabilized and you were transferred to the
medical floor. Your blood pressure started to increase and we
slowly added your blood pressure medication back. You were felt
to be stable and be transferred to a rehab facility for further
care.
Your new medications changes include:
Imdur was decreased from 60 mg daily to 30 mg daily.
Amlodipine 5 mg daily was held. If your blood pressure
increases, your doctor should consider re-starting this
medication.
You should contact your primary care office or go directly to
the emergency room if you experience significant dizziness,
lightheadedness, difficulty breathing, significant chest pain,
or any other symptom that is concerning to you.
Followup Instructions:
You are scheduled to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Date and time: [**Last Name (LF) 2974**], [**8-22**] at 11:50AM
Location: [**Hospital6 5242**] CENTER, [**Location (un) 5243**],
[**Location (un) **],[**Numeric Identifier 2260**]
Phone number: [**Telephone/Fax (1) 798**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
]
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12817, 12939
|
6502, 10760
|
361, 367
|
13104, 13113
|
4767, 4767
|
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|
4056, 4323
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|
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|
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|
5119, 6479
|
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|
302, 323
|
395, 1771
|
4784, 5102
|
1793, 3108
|
3124, 4040
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,442
| 198,899
|
32211
|
Discharge summary
|
report
|
Admission Date: [**2163-1-8**] Discharge Date: [**2163-1-22**]
Date of Birth: [**2086-7-12**] Sex: F
Service: MEDICINE
Allergies:
Egg / Morphine Sulfate / Propofol Analogues
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
1. Cardiac catheterization [**2163-1-12**]
2. Cardiac stenting of left main coronary artery and right
coronary artery [**2163-1-12**]
3. Tunneled hemodialysis line placement [**2163-1-17**]
History of Present Illness:
Mrs. [**Known lastname **] is a 76 year old woman with CAD (S/p BMS to mid
LAD in [**2159**]), sCHF (EF 40%), PVD s/p R axillobifemoral bypass
with graft which the fem-fem is now occluded, carotid
endarterectomy x 2 on the left last in [**2158**], s/p SMA PCI, COPD
(on 2L NC), PEs on coumadin who presents intubated/sedated from
[**Hospital3 **] in setting of acute pulmonary edema,
respiratory failure, oliguric [**Last Name (un) **], and critical left main
disease.
.
Patient was transferred from [**Hospital3 1443**] Hospital. She
had recently been discharged after treatment of pneumonia
(unknown antibiotic course), and while at home in days after
discharge, developed progressive dyspnea and possible fever.
She denied sputum production or cough. BNP on admission was
1000, up from 600 during previous admission for pneumonia. She
was started on Zpack, ceftriaxone, and levofloxacin for
pneumonia/COPD exacerbation, and given IV lasix 20mg tid for
pulmonary edema. She does not take lasix as an outpatient. She
was noted to have a Cr of 1.4 on admission, which rose to 4.8
with diuresis. Lasix was discontinued and renal consult was
obtained, who recommended stopping lasix, giving IVF for
pre-renal azotemia, and changing levofloxacin to ampicillin.
She was also found to have an enterococcus UTI and started on
unasyn. ID and heme/onc consultations were obtained for
leukocytosis 19 with left shift. Both agreed that leukocytosis
was likely reactive, but to treat pneumonia and UTI, and to
follow-up with outpatient records. Patient does have chronic
leukocytosis and thrombocytosis noted during prior admission to
[**Hospital1 **] as well. Per heme/onc consultation at that time, pattern
appeared less likely to be MDS, more likely to be reactive,
possibly related to iron deficiency as well. Patient was
initiated on HD 4 days prior to transfer, received third run of
HD today, during which she developed acute left-sided chest
pain, [**8-31**], not radiating. She developed severe respiratory
distress, was intubated, had then noted to have new
inferiorlateral ST depressions on her EKG (I and aVL and V6)
then goes to cath lab where they find 90% LM, 70% RCA, but no
interventions were performed.
She was transferred to the [**Hospital1 18**] CCU for further management.
.
Unable to obtain ROS as patient is intubated.
Past Medical History:
CAD s/p PCI to LAD ([**2159**])
CHF
L CEA
R axillobifemoral bypass with graft
mult foot/ankle surgeries
HTN
COPD on home O2 (2L nightly, occasionally during the day)
s/p nephrectomy
incarcerated umbilical hernia s/p repair [**8-29**]
acute cholecystitis s/p cholecystostomy drainage [**8-29**]
asthma
PE x 2 on coumadin
CKD
Ischemic colitis, chronic s/p celiac and SMA stents
Bladder cancer: Recent treatment history at [**Hospital3 **],
she's had 3 procedures in the past couple years including
chemical bath of the bladder. Last 2 checks were clear.
Urologist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20672**] [**Telephone/Fax (1) 75317**]
[**URL 75318**].
Social History:
Patient lives alone in an apartment building. She has one son
that lives in another town. Sister who used to live in the same
building passed away. Only goes grocery shopping once per month
at times runs out of milk and bread.
Hx of Tobacco 80 pack years
No ETOH, No drug use
Family History:
Father MI @ 60, mother AD, sister DM2. No hx of DVTs, PEs. No
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T98.4 BP= 111/59 HR=91 RR=20 O2 sat= 98(intubated)
GENERAL: intubated, sedated, but arousable and can answer yes/no
to questions
HEENT: NCAT. Sclera anicteric. PERRL.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: intubated, anterior lung exam revealed no crackles,
wheezes or rhonchi.
ABDOMEN: Normoactive bowel sounds, soft, NTND.
EXTREMITIES: cold, clamy, faintly palpable DP and PT pulses b/l
NEURO: sedated but arousable, able to squeeze with both hands
and move both feet to command
.
PHYSICAL EXAM ON DISCHARGE:
97.9 89 139/46 20 98% on 2L
GENERAL: awake, in NAD, AOx2
HEENT: NCAT. Sclera anicteric. PERRL.
CARDIAC: RRR, normal S1, S2. Grad [**11-26**] ejection systolic murmur,
loudest in RUSB. No thrills, lifts. No S3 or S4.
LUNGS: anterior lung exam revealed some crackles in bases, but
no wheezes or rhonchi.
ABDOMEN: Normoactive bowel sounds, soft, NTND.
EXTREMITIES: faintly palpable DP and PT pulses b/l
NEURO: Patient AOX2, but still appears very weak. No gross
deficits
Pertinent Results:
Labs on Admission:
[**2163-1-8**] 10:00PM BLOOD WBC-37.7*# RBC-4.37 Hgb-12.1 Hct-36.3
MCV-83 MCH-27.7# MCHC-33.3 RDW-19.3* Plt Ct-1013*
[**2163-1-8**] 10:00PM BLOOD Neuts-76* Bands-6* Lymphs-2* Monos-6
Eos-2 Baso-0 Atyps-0 Metas-7* Myelos-1*
[**2163-1-8**] 10:00PM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-1+ Ovalocy-2+ Burr-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 24904**]
[**2163-1-8**] 10:00PM BLOOD PT-15.0* PTT-105.8* INR(PT)-1.4*
[**2163-1-8**] 10:00PM BLOOD Glucose-135* UreaN-19 Creat-2.6*# Na-142
K-5.0 Cl-102 HCO3-24 AnGap-21*
[**2163-1-8**] 10:00PM BLOOD LD(LDH)-671* CK(CPK)-235* TotBili-0.5
[**2163-1-8**] 10:00PM BLOOD Calcium-8.9 Phos-6.6*# Mg-2.0
[**2163-1-8**] 10:00PM BLOOD Hapto-305*
.
Cardiac Enzymes:
[**2163-1-8**] 10:00PM BLOOD CK-MB-24* MB Indx-10.2* cTropnT-0.55*
[**2163-1-9**] 02:04AM BLOOD CK-MB-23* MB Indx-9.6* cTropnT-1.00*
[**2163-1-9**] 04:16PM BLOOD CK-MB-11* MB Indx-5.2 cTropnT-1.18*
.
Lactates:
[**2163-1-8**] 10:37PM BLOOD Lactate-2.7*
[**2163-1-9**] 04:33PM BLOOD Lactate-1.0
.
TTE [**2163-1-9**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears moderately-to-severely
depressed (ejection fraction 30 percent) secondary to akinesis
of the septum and hypokinesis of the anterior free wall,
inferior free wall, and lateral wall. Contractile function of
the posterior wall appears preserved. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
.
Renal Ultrasound [**2163-1-9**]:
IMPRESSION:
No hydronephrosis. No change from a CT in [**2160-1-20**].
.
CARDIAC CATH [**2163-1-12**]
COMMENTS:
1. Successful PCI of the LMCA with a 3.0x15mm Promus DES,
post-dilated
to 4.0mm.
2. Successful PCI to the RCA with a 3.0x23mm Promus DES,
post-dilated to
3.5mm.
3. Terumo band to the right radial artery.
4. No complications.
.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PCI to the LMCA and RCA with Promus DES.
3. Patient to remain on aspirin and clopidogrel indefinitely,
without
interruption.
4. No complications.
.
CT head [**1-15**]
IMPRESSION:
1. Left occipital lobe loss of [**Doctor Last Name 352**]-white differentiation could
be related an acute on chronic infarct. An MR may be obtained
for further evaluation.
2. Left maxillary sinus fluid.
.
MRI head [**2163-1-16**]
IMPRESSION:
1. Chronic infarction identified in the left parietooccipital
region with
extensive area of encephalomalacia, associated chronic
microvascular ischemic disease is present.
2. Punctate areas of restricted diffusion are noted in the
subcortical white matter on the right frontal lobe, left frontal
convexity and right prefrontal region, likely consistent with
small thromboembolic ischemic changes.
3. There is narrowing of the left internal carotid siphon and
distal vascular branches, likely consistent with atherosclerotic
disease as described above.
4. Mucosal thickening is noted on the left maxillary sinus with
air-fluid
levels, possibly consistent with ongoing inflammatory process.
.
Interventional [**2163-1-17**]
IMPRESSION: Successful exchange of a temporary hemodialysis
catheter for a 23 cm tunneled hemodialysis catheter. The
catheter tip is in the right atrium. The line is ready to use.
.
CXR [**2163-1-19**]:
FINDINGS: In comparison with the study of [**1-18**], the monitoring
and support
devices are essentially unchanged. Continued opacification at
the left base with blunting of the costophrenic angle,
consistent with atelectasis and small effusion. Less prominent
changes are seen on the right.
.
Carotid Ultrasound [**2163-1-20**]
Impression: Right ICA 70-79% stenosis. Cannot rule out more
severe stenosis due to calcification. Consider CTA if clinically
indicated.
Left ICA no stenosis.
On Discharge:
140 98 50
----------------< 106
4.8 30 4.2
Ca: 8.8 Mg: 2.6 P: 7.4 ∆
WBC-17.4
Hb-8.7
Hct-25.7
Plt-540
PT: 26.1 PTT: 150 INR: 2.5
Brief Hospital Course:
Primary Reason for Hospitalization:
Mrs. [**Known lastname **] is a 76 year old woman with CAD (S/p BMS to mid
LAD in [**2159**]), sCHF (EF 40%), PVD s/p R axillobifemoral bypass
with graft which the fem-fem is now occluded, carotid
endarterectomy x 2 on the left last in [**2158**], s/p SMA PCI, COPD
(on 2L NC), PEs on coumadin who presents intubated/sedated from
OSH in setting of acute pulmonary edema, respiratory failure,
oliguric [**Last Name (un) **], and critical left main disease.
.
Active Diagnoses:
# CAD: Cardiac cath showed 90% LM, 70% RCA lesion, no
intervention was performed initially. Initial EKG at OSH showed
severe STE in I and [**Last Name (LF) **], [**First Name3 (LF) **] depressions in lateral leads.
Repeat EKG on transfer looked improved although still with STE
in I and [**First Name3 (LF) **]. Patient still endorses chest pain when asked.
Patient was initially on a heparin gtt and nitro gtt. CT
surgery consultation believed patient was too high risk to take
for CABG, due to multiple comorbidities. Thus, patient was
taken to cardiac cath and DES were placed in left main and RCA.
She was continued on coreg 3.125 mg [**Hospital1 **], captopril 6.25 mg tid,
plavix 75 mg daily, atorvastatin 80 mg daily, aspirin 325 mg
daily. She is to not stop aspirin or plavix without speaking to
her cardiologist.
.
# Respiratory Distress. Patient was initially intubated at OSH
for respiratory distress, thought to be secondary to pneumonia
and pulmonary edema. Patient was previously hospitalized a week
prior to this current presentation for pneumonia (unclear
course), discharged, and repeat CXR on admission looks like
worsened pneumonia/CHF. Patient was diuresed at OSH, but
developed acute on chronic renal failure. Renal consultation
team thought was pre-renal azotemia, so patient was given IVF,
and may have redeveloped pulmonary edema. At baseline, patient
has severe COPD on 2L oxygen at home. She was transferred
intubated, sedated on CMV 400 x 14 50% FiO2. Fentanyl/versed
was used for sedation, as patient is allergic to propofol. CVVH
was later initiated for volume management. Patient did well
with RISB and SBTs, and was extubated once volume removal was
achieved with dialysis. She remains on 2L NC on discharge, but
oxygenates well on room air to 2L NC.
.
# Altered Mental Status: As sedation was turned off to prepare
patient for extubation, it was noted that she had prolonged AMS
and was not able to follow commands and did not have intact gag
reflex. CVVH was continued to correct toxic-metabolic
disturbances. CT head was obtained that showed question of
ischemic injury in watershed zone between left MCA/PCA
territories. A MRI brain was obtained that showed no such
infarction, but small areas of acute ischemia in the left
frontal lobe. Neurology consult was called, and these areas are
believed to be too small to be the cause of AMS. Neurology
recommended obtaining a carotid duplex for further evaluation of
the acute ischemia. Although patient had R ICA stenosis,
intervention was felt to be too high risk, and risks would
likely outweigh benefits. Her mental status slowly improved and
she is near baseline per family on discharge.
.
# CKD: Patient has solitary kidney, CKD Stage III. On
admission to OSH, Cr was 1.4, but with diuresis had bumped to
4.8. Was initially thought to be pre-renal, but after
discontinuing lasix and giving IVF, did not show improvement in
renal function, so likely ATN. Was initiated on HD at OSH 4
days prior to transfer, had received 3 cycles at OSH. OSH
work-up revealed that patient may have renal artery stenosis as
evidenced by atrophic kidney (however, this could just be from
CKD)and elevated renin and aldosterone. Patient was maintaed on
CVVH during this hospitalization. A temporary dialysis catheter
was placed, and a tunneled line was then placed. PPD was
confirmed negative. She will continue hemodialysis in rehab and
outpatient setting. She is discharged on nephrocaps. Epo should
be initited with next session of dialysis. Of note, renal
recovery is possible for this patient and the need for HD should
be continuously reassessed.
.
# UTI: Had enterococcus UTI at OSH and received 5 day course of
Unasyn prior to transfer. Upon calling OSH for
speciation/sensitivity, it was found that enterococcus only
sensitive to vancomycin, so patient has finished a 14 day course
on [**2163-1-22**].
.
# Leukocytosis: Patient had leukocytosis at OSH up to 30. ID
and heme consults both thought could be reactive, secondary to
infectious processes (pneumonia, UTI). Patient is also noted to
have chronic leukocytosis and thrombocytosis, as noted in
discharge summary in [**2159**]. At that time, heme/onc consultation
also thought findings were reactive and not associated with
hematologic malignancy. Now, WBC 37.7 with 6% bands points to
infectious etiology. As patient was treated for infection,
leukocytosis trended down to 20s. BCR-ABL pcr looking for CML
was negative. Hematology/oncology team felt that this could be
a smoldering myeloproliferative disease with overlying component
of infection. JAK 2 returned positive, and there was a likely
presumptive diagnosis of essential thrombocytosis vs other
myeloproliferative disorders.
.
# Thrombocytosis: Patient has thrombocytosis to the millions.
Although this could be reactive, should assess other possible
sources and hematologic disorder. Jak2 mutation looking for
myeloproliferative diseases was positive. Platelet count
trended down with treatment of infection, indicating a probably
reactive etiology as well. Plt count on discharge 540k.
.
# Vasculopathy: Patient is s/p R axillobifemoral bypass with
graft which the fem-fem is now occluded, carotid endarterectomy
x 2 on the left last in [**2158**], s/p SMA PCI. She has been
chronically anticoagulated on coumadin, but coumadin was held
for HD line placement at OSH. Patient was later started on
plavix and aspirin this admission and maintained on a heparin
gtt. Heparin gtt was discontinued when INR was 2.5. Goal INR
[**12-24**].
.
#. Code Status: FULL
.
Transitional Issues:
# Continue HD sessions at rehab and outpatient setting
# Speak and Swallow consult
# Bladder Scan daily, if >300cc, please straight cath
Medications on Admission:
Clopidogrel 75 mg PO daily
Tiotropium Bromide 18 mcg Capsule,1 inh daily
Fluticasone-Salmeterol 250-50 mcg/Dose Disk 1 inh [**Hospital1 **]
Aspirin 325 mg Tablet PO daily
Coumadin 3 mg PO daily
Diltiazem HCl sustained release 120 mg PO daily
Clonidine 0.1 mg mg PO TID
Nitroglycerin 0.3 mg SL PRN chest pain
Metoprolol Tartrate 100 mg PO BID
Simvastatin 80mg PO daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): on days of HD, please give after HD.
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): On days of HD, please give after HD.
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
13. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
14. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
15. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for Chest pain.
18. Epogen Injection
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
PRIMARY:
1. Acute coronary syndrome
2. End stage renal disease, on hemodialysis
3. Essential thrombocytosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
You were transferred to our cardiology ICU as you were having a
heart attack. While here, you had a stent placed in your left
main coronary artery and right coronary artery on RCA [**2163-1-12**].
There were no complications. You were on a beathing machine and
mechanical ventilator, which you recovered from.
.
You required dialysis during your inpatient stay, and will need
dialysis on discharge. You will be set up with a kidney doctor
and appointment on discharge. Please have your kidney doctor
start Epo with hemodialysis
.
You were noted to have a complicated urinary tract infection.
You are receiving vancomycin therapy, which will be dosed per
dialysis protocol. You have completed the entire course of
antibiotics for this urinary tract infection.
.
You were also noted to have high white blood cell count and high
platelet count, which is concerning for a myeloproliferative
disorder. You also had a test that was positive for a JAK2
mutation, which is often found in myeloproliferative disorders.
You will have follow-up for this condition in hematology clinic.
.
You had several medication changes while here in the hospital.
Please take your medications as prescribed below.
Acetaminophen 1000 mg PO/NG TID
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
Aspirin 325 mg PO/NG DAILY
Atorvastatin 80 mg PO/NG DAILY
Clopidogrel 75 mg PO/NG DAILY
Captopril 6.25 mg PO/NG TID
Carvedilol 3.125 mg PO/NG [**Hospital1 **]
Citalopram 10 mg PO/NG DAILY
Docusate Sodium 100 mg PO/NG [**Hospital1 **]
Ipratropium Bromide Neb 1 NEB IH Q6H
Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Milk of Magnesia 30 mL PO/NG Q6H:PRN constipation
Nephrocaps 1 CAP PO DAILY
Nitroglycerin SL 0.3 mg SL PRN Chest pain
Ranitidine 150 mg PO/NG Q24H
Senna 1 TAB PO/NG [**Hospital1 **]
Warfarin 3 mg PO/NG DAILY
Start Epogen as prescribed by your kidney doctor.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: HEMODIALYSIS
When: SATURDAY [**2163-1-22**] at 7:30 AM
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2163-3-17**] at 2:00 PM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2163-3-17**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
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21,035
| 121,418
|
18344
|
Discharge summary
|
report
|
Admission Date: [**2176-12-10**] Discharge Date: [**2176-12-24**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
woman, originally admitted on [**2176-10-30**] for C2 pannus
with calcification and significant narrowing of the cervical
medullary junction. The patient originally presented due to
fall and a C spine film at that time showed a narrowing of
the cervical medullary junction. The patient had difficulty
with ambulation over the last two years and worsening over
the last three to four months, causing the use of a cane.
She left rehabilitation a week ago and had urinary tract
infection on discharge. She finished Levaquin yesterday
using a C collar at all times. She is admitted preoperative
for a transoral odontoidectomy and occipital cervical fusion.
On physical examination, her temperature was 98.7; blood
pressure 112/60; heart rate of 78; respiratory rate of 18;
saturations 98%. She has a past medical history also of
diabetes, urinary tract infection, bundle branch block.
PHYSICAL EXAMINATION: In general, she was awake, alert and
cooperative, in no acute distress. HEAD, EYES, EARS, NOSE
AND THROAT: Pupils are equal, round, and reactive to light
and accommodation. Extraocular movements full. Mucous
membranes were moist. Pulmonary: Lungs clear bilaterally.
Cardiac: Regular rate and rhythm. S1 and S2. Abdomen:
Soft, nontender, nondistended, positive bowel sounds.
Extremities: No clubbing, cyanosis and edema.
Neurologically: Awake, alert and oriented times three with
slight right drift and slight right facial droop. She was
[**6-3**] in all muscle groups. Her reflexes were 3+ at the knees
and 3+ at the ankles; bilaterally 2+ in the upper
extremities. She was admitted for preoperative.
HOSPITAL COURSE: On [**2176-12-11**], she underwent transoral
resection of odontoid and associated pannus. She also
underwent an occipital to C2 fusion. Her vital signs remained
stable. She was intubated and stayed intubated on the first
night postoperatively. She was awake, alert, following
commands at the time. Pupils were 3 down to 2 mm and briskly
reactive. She had strength, moving all extremities with good
strength.
On postoperative day number one, she was extubated. She
tolerated extubation for approximately four to five hours and
then became stridorous, requiring reintubation. She did get
reintubated but also had an episode of cardiac arrest where
she received compressions for about one to two minutes and
then had a heart rate back. She moved everything about 10 to
15 minutes after the event, after she was intubated. She
woke up, moved everything and followed commands. She stayed
intubated for another 3 to 4 days, at which time she was
again extubated which she tolerated well. Her vital signs
were stable. She was afebrile. She was moving all
extremities with good strength, although very confused and
agitated at times. She was extubated on [**2176-12-16**]. She
tolerated that well. Her vital signs remained stable. She
was afebrile, though as I said, she was intermittently
confused and agitated. She was out of bed to chair with
assistance. She was transferred to the regular floor on
[**2176-12-17**]. She was seen by speech and swallow who felt that
she should remain n.p.o. and just take clear liquids. She
was able to tolerate thin liquids but not solids. She
remained n.p.o. with just fluids until [**2176-12-23**] when she had
a repeat video swallow study which showed that she was able
to tolerate soft solids and thin liquids. Her vital signs
remained stable. Her mental status is still somewhat confused
but better. She was seen by the neurology service. She had
a magnetic resonance scan which showed no evidence of stroke.
Neurology attending saw her and neurology thought her
confusion was multifactorial due to sleep deprivation. Her
toxic metabolic work-up was negative for laboratory studies
within normal limits. She did have an episode of tachycardia
and ventricular tachycardia. Cardiology saw her and felt
that there was no necessary treatment for that. That did
resolve spontaneously. She remained neurologically stable
and was transferred to rehabilitation on [**2176-12-24**].
MEDICATIONS ON TRANSFER:
Percocet one to two tabs p.o. every four hours prn to be
crushed.
Atorvistatin 10 mg p.o. q. day.
Levofloxacin 500 mg p.o. q. 24 hours.
Decadron 2 mg p.o. q. eight hours, to be weaned off over a
week.
Metoprolol 25 mg p.o. twice a day.
Artificial tears, one to two drops o.u. prn.
Famotidine 20 mg p.o. twice a day.
Heparin 5000 units subcutaneous q. 12 hours.
Albuterol nebs, q. six hours prn.
The patient's staples were removed on [**2176-12-23**]. Steri-Strips
were in place. They should follow-up within a week. Her
incision should be clean, dry and intact. If there is any
redness, drainage or fever which occurs, Dr. [**Last Name (STitle) 1327**] should be
notified immediately. Her condition was stable at the time
of discharge. Physical therapy and occupational therapy
cleared her for discharge to rehabilitation.
[**Name6 (MD) 1339**] [**Last Name (NamePattern4) 1340**], M.D. [**MD Number(1) 1341**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2176-12-23**] 03:04
T: [**2176-12-23**] 16:47
JOB#: [**Job Number 50539**]
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|
4246, 5339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,575
| 156,937
|
2292
|
Discharge summary
|
report
|
Admission Date: [**2181-3-26**] Discharge Date: [**2181-3-29**]
Date of Birth: [**2131-12-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
diahrrea, bleeding per rectum
Major Surgical or Invasive Procedure:
colonoscopy
EGD
History of Present Illness:
This is a 49 y.o. man w/ pmh significant for hypertension,
anemia, paroxysmal a-fib on aspirin, H.Pylori, presenting with
bright red blood per rectum. The patient reports waking from his
sleep two nights ago with severe abdominal pain. He then had a
diarrhea bowel movement. After his bowel movement the patient
reports almost passing out. He lied down on the floor and then
crawled back to bed. The following day he had a second bowel
movement which was gross blood. He also noticed palpitations
with minimal exertion, and he measured his blood pressure at
home which was 90/50. He went to the ED and had another grossly
bloody stool. Of note, he denies any F/C, HA, CP, SOB, n/v,
dysuria, bruising or other bleeding. He has not had any exotic
foods or travel. His wife was recently ill with diarrhea and
given Flagyl. He does take 2 advil every day which is not new
for him
.
In the ED, T 97.6, HR 100, BP 109/69, RR 16, 100%RA. Exam
notable for brown guaiac + stool, no obvious fissures. NG lavage
negative. He did have an additional episode of BRBPR Hct 28 and
stable x2. Given Protonix 40mg IV and 2L NS. he was admitted to
the MICU and his vital signs remained stable 147/74, Hr 81. GI
saw him in the ICU and recommended egd and colonoscopy.
Past Medical History:
1. Paroxysmal A fib on baby ASA
2. HTN
3. Hyperlipidemia
4. OSA
5. Restless Leg Syndrome
6. EGD in [**1-7**] with gastritis. Colonoscopy in [**2175**] with
hemorrhoids, otherwise unremarkable
Social History:
He is married, has one child. He works at [**Company 4700**], is
the IT Director for the law school. He denies tobacco or alcohol
use.
Family History:
No history of cardiac disease. Father with anemia, mother died
of liver cancer. Father died of biliary cancer
Physical Exam:
Vitals: T:98.4 P:81 BP:147/74 R: SaO2: 97%RA
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty
Pertinent Results:
[**2181-3-26**] 12:10PM BLOOD WBC-9.2 RBC-3.29* Hgb-10.0* Hct-28.4*
MCV-86 MCH-30.4 MCHC-35.2* RDW-12.7 Plt Ct-186
[**2181-3-29**] 04:50AM BLOOD WBC-7.3 RBC-3.27* Hgb-10.1* Hct-28.2*
MCV-86 MCH-30.9 MCHC-35.8* RDW-12.9 Plt Ct-180
[**2181-3-26**] 08:17PM BLOOD PT-13.7* PTT-26.0 INR(PT)-1.2*
[**2181-3-28**] 07:15PM BLOOD PT-12.5 PTT-27.1 INR(PT)-1.1
[**2181-3-26**] 12:10PM BLOOD Glucose-170* UreaN-30* Creat-1.5* Na-138
K-3.7 Cl-102 HCO3-28 AnGap-12
[**2181-3-29**] 04:50AM BLOOD Glucose-113* UreaN-17 Creat-1.1 Na-142
K-4.1 Cl-107 HCO3-27 AnGap-12
[**2181-3-27**] 03:08AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.8
[**2181-3-29**] 04:50AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9
[**2181-3-28**] 07:15PM BLOOD calTIBC-244* VitB12-486 Folate-GREATER TH
Ferritn-132 TRF-188*
.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 12029**],[**Known firstname 12030**] [**2131-12-10**] 49 Male [**Numeric Identifier 12031**] [**Numeric Identifier 12032**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 5085**]/DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12033**], [**Doctor Last Name 1057**],[**Doctor First Name 12034**]/mtd
SPECIMEN SUBMITTED: GI BIOPSY (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
[**2181-3-28**] [**2181-3-28**] [**2181-4-3**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 12033**]/cma??????
Previous biopsies: [**Numeric Identifier 12035**] ANTRUM BIOPSY, DUODENUM BIOPSY
[**Numeric Identifier 12036**] GI BX'S/hg/tc.
[**Numeric Identifier 12037**] LIPOMA BACK/ss.
[**Numeric Identifier 12038**] RENAL STONES/kb.
DIAGNOSIS:
Colon, splenic flexure, biopsy:
Colonic mucosa with non-specific mild congestion most likely
representing preparation effect.
Clinical: Anemia, GI bleed.
Gross: The specimen is received in one formalin container,
labeled with the patient's name, "[**Known lastname 11949**], [**Known firstname **]", the medical
record number and additionally labeled "splenic flexure". It
consists of multiple tissue fragments measuring up to 0.3 cm,
entirely submitted in cassette A.
.
CTA PELVIS W&W/O C & RECONS [**2181-3-29**] 10:25 AM
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS
Reason: embolism of mesenteric artery.
Field of view: OP Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with afib, ischemic colitis at splenic flexure.
REASON FOR THIS EXAMINATION:
embolism of mesenteric artery.
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 49-year-old man with atrial fibrillation and
ischemic colitis at splenic flexure. Evaluate for embolism of
the mesenteric artery.
COMPARISON: None.
TECHNIQUE: MDCT-acquired contiguous axial slices were obtained
with and without administration of intravenous contrast. 150 cc
of intravenous Optiray was administered. Multiplanar reformats
including maximum-intensity projections were obtained. Three
dimensional volume-rendered reconstructions were also generated
for better evaluation of the vascular anatomy.
CTA OF THE ABDOMEN AND PELVIS: The abdominal aorta, celiac
artery, superior mesenteric artery, inferior mesenteric artery,
and their branches are patent without evidence of stenosis or
embolism or thrombosis. Multiplanar reformats and
volume-rendered images also demonstrate no focal areas of
stenosis or narrowing. Accessory left renal arteries are noted
incidentally, one supplying the superior and the second
supplying the anterior pole of the kidney. The main renal artery
has its normal origin from abdominal aorta and enters the hilar
structures.
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver
demonstrates diffusely low attenuation, suggestive of fatty
infiltration. However, no focal hepatic lesions or masses are
identified. The gallbladder, spleen, pancreas, stomach,
intra-abdominal bowel loops are unremarkable. There is no
evidence of ischemic colitis on the current study. The colonic
wall and the pericolonic mesenteric fat appear unremarkable
without evidence of stranding or edema. No pathologic
retroperitoneal or mesenteric adenopathy is noted. A low-
attenuation lesion measuring 17.7 mm x 15 mm is noted in the
lower pole of the right kidney, is noted, likely represent a
simple cyst. Another low attenuation lesion is noted in the
superior pole of the left kidney measuring 1 cm x 0.9 cm, may
represent a simple cyst.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid
colon, prostate, seminal vesicles, urinary bladder, pelvic bowel
loops are unremarkable. There is no pathologic pelvic or
inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic osseous
lesions are seen. There is evidence of mild scoliosis at the
L3-L4 level with endplate sclerosis due to degenerative changes
at that level.
IMPRESSION:
1. No evidence of mesenteric artery embolism or ischemic
colitis.
2. Bilateral renal hypoattenuating lesions, likely represent
renal cyst. 3. Incidental note of accessory left renal arteries
supplying the superior and inferior poles of the left kidney in
addition to the main renal artery.
.
EGD: Impression: Normal mucosa in the whole esophagus
Erythema and congestion in the antrum compatible with mild
gastritis
Normal mucosa in the first part of the duodenum and second part
of the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: 1. Continue PPI daily
2. Colonoscopy for further evaluation of anemia.
Additional notes: The procedure was done with attending
supervision.
.
Colonoscopy:
Impression: Grade 1 internal hemorrhoids
Erythema and congestion in the splenic flexure compatible with
ischemic colitis (biopsy)
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: 1. Follow biopsy results
2. [**Name (NI) **] pt follow up with Dr. [**First Name (STitle) 2643**].
Additional notes: The efficiency of colonoscopy in detecting
lesions was discussed with the patient. It was explained that
colon cancer and colon polyps on rare occasions may be missed
during a colonoscopy.The procedure was done with attending
physician and GI fellow.
Thank you Dr. [**Last Name (STitle) 2739**] for allowing me to participate in the care
of Mr. [**Known lastname 11949**].
Brief Hospital Course:
49M with pAfib on ASA, HTN, past gastritis and hemorrhoids who
presents with abdominal pain,1 episode of diarrhea and 2
episodes or BRBPR
.
.
#: Bright Red Blood Per Rectum: Patient was admitted to the MICU
and monitored overnight without complications. he was
transferred to the floor to the following and underwent
colonoscopy and EGD. EGD was unrevealing, and colonoscopy
revealed colitis at the splenic flexure, consistent with
ischemic colitis. Given the patient's history of atrial
fibrillation, a CTA abdomen was done to ensure that the colitis
was not secondary mesenteric embolism. CTA abdomen did not show
occlusion of the mesenteric vessels. The etiology of ischemic
colitis is thought secondary to hypotension, after the patient
had a pre-syncopal episode. his pre-syncope was thought to be
caused by diahhrea from food poisoning. The patient was
discharged home on omeprazole.
.
#ARF: Baseline 0.8. presented with 1.5, improved to 1.1 with
IVF. Likely pre-renal in the setting of bleed.
.
#Afib: CHADS2 score 1. Low risk for stroke. Was on baby aspirin
for the last month. His aspirin was held in the setting of
bleed, and restarted at discharge.
.
# HTN: His antihypertensive medications were held in the setting
of GI bleeding. They were restarted at discharge.
.
# Lipids: Continued lipitor
.
# OSA: Wife to bring in home BiPAP machine
.
#Restless leg: Will continued mirapex, requip, cymbalta.
Medications on Admission:
Toprol XL 100mg [**Hospital1 **]
Mirapex 0.125mg [**Hospital1 **]
Benicar and hydrochlorothiazide combination of 40 mg and 25 mg
Daily, Lisinopril [**Hospital1 **] (uncertain dose)
Lipitor 20mg Daily
Aldactone
Cymbalta 60mg Daily
Requip 0.75mg DAily
ASA 81mg Daily
Discharge Medications:
1. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day.
2. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Olmesartan-Hydrochlorothiazide 40-25 mg Tablet Sig: One (1)
Tablet PO once a day.
5. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Requip 0.25 mg Tablet Sig: Three (3) Tablet PO once a day.
7. aldactone
daily
8. lisinopril
twice daily
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
10. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Ischemic Colitis
Syncope
.
Secondary Diagnosis
Hypertension
Hyperlipidemia
OSA
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for evaluation of bleeding per
rectum and lightheadedness. Our evaluation revealed that you
have an area of ischemic colitis. It is most likely that this
area of colitis is due to an episode of low blood pressure.
.
You were started on a new medication named omeprazole.
Continuation of this medication will be addressed by Dr. [**First Name (STitle) 2643**]
on [**2181-4-20**].
.
Please call your doctor or return to the hospital if you
experience further blood in your stool, lightheadedness, or any
other concerning symptoms.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2181-9-4**] 4:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2837**], MD , Gastroenterology,
Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2181-4-20**] 12:45
.
You have an appointment with your PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2739**] [**Telephone/Fax (1) 2740**]
on [**2181-4-5**]
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"327.23",
"285.9",
"557.9",
"584.9",
"272.4",
"401.9",
"569.3",
"276.52",
"455.0",
"276.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"96.07",
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
11794, 11800
|
9258, 10674
|
345, 363
|
11941, 11948
|
2807, 5314
|
12561, 13139
|
2025, 2136
|
10990, 11771
|
5351, 5415
|
11821, 11920
|
10700, 10967
|
11972, 12538
|
2151, 2708
|
276, 307
|
5444, 9235
|
391, 1641
|
2723, 2788
|
1663, 1857
|
1873, 2009
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,130
| 158,789
|
3866
|
Discharge summary
|
report
|
Admission Date: [**2142-5-7**] Discharge Date: [**2142-5-18**]
Date of Birth: [**2082-1-18**] Sex: F
Service: MICU [**Location (un) **]
HISTORY OF THE PRESENT ILLNESS: The patient is a 60-year-old
female with a history of morbid obesity/diabetes type 2,
hypertension, anemia, diverticulosis, who also has a diabetic
foot ulcer, status post partial calcanectomy and debridement
of left heel ulcer for osteomyelitis on [**2142-5-9**]. The
patient was initially admitted on [**2142-5-7**] after falling to
the floor and unable to get up for almost seven hours. The
patient did not maintain any loss of consciousness nor any
head trauma. Upon admission, her white blood count was noted
to be 26,000. She was also found to have evidence of
rhabdomyolysis with a total CK of 4,860, and increased
creatinine function. She has a long-standing heel ulcer,
chronic osteomyelitis for which upon admission had some blood
cultures that showed two out of two bottles positive for
Staphylococcus aureus sensitivities and was started on
antibiotics.
On [**2142-5-9**], the patient underwent a partial calcanectomy
and left heel debridement. Preoperatively, the patient was
noted to have increased troponins to 3.2 with some acute EKG
changes as well as chronic anemia postoperatively. Later
that night, the patient had decreased blood pressures to 70
systolic and was given several boluses of IV fluids without
significant changes in hemodynamics. The patient was
tachycardiac as well as with the decreased urine output. It
was also noted that the patient was disoriented and,
therefore, was transferred to the MICU on [**2142-5-11**] for rule
out sepsis due to Staphylococcus aureus osteomyelitis.
PAST MEDICAL HISTORY:
1. Diabetes type 2 with neuropathy and nephropathy.
2. Hypertension.
3. Anemia.
4. Diverticulosis.
5. Recurrent UTIs.
6. Peripheral vascular disease with diabetic foot ulcer,
with past history of osteomyelitis.
7. Chronic renal failure.
MEDICATIONS IN THE HOSPITAL:
1. Acetaminophen.
2. Heparin 5,000 q.a.
3. Trazodone.
4. Zolpidem q.h.s. p.r.n.
5. Sertraline 100 q.d.
6. Aspirin, enteric-coated 325.
7. Percocet p.r.n.
8. Insulin sliding scale.
9. Vancomycin.
10. Levaquin.
11. Clindamycin.
12. Fluconazole.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives alone in an apartment,
with a supportive family. The patient does not smoke or
drink nor is involved in recreational drug use.
REVIEW OF SYSTEMS: The patient denied headache, fevers,
chills, cough, shortness of breath, no chest pain, no
abdominal pain, no nausea, vomiting.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.2, blood pressure 82/30, heart rate 100, respiratory rate
20, oxygen saturation 99% on room air. Finger stick was 118.
General: The patient was a morbidly obese African-American
female in no acute distress, appears comfortable. HEENT:
Normocephalic, atraumatic, pupils equal and round to light.
The oropharynx was slightly dry. The skin was warm, dry, and
anicteric. Neck: Supple. Noted was a right-sided internal
jugular central line in place. No surrounding erythema nor
discharge. Unable to assess neck veins due to obesity.
Lungs: Clear to auscultation anteriorly. Cardiovascular:
S1, S2, noted tachycardia, distant sounds. No murmurs, rubs,
or gallops. Abdomen: Obese, soft, nontender, nondistended.
Extremities: The patient had a pressure dressing at the left
heel, clean, dry, and intact. Neurologic: The patient was
oriented to place, time, as well as name. Cranial nerves II
through XII were grossly intact.
LABORATORY/RADIOLOGIC DATA: The patient's white blood cell
count was 21, hematocrit 27.5, status post 2 units of packed
red blood cell infusion. The patient's platelets were
123,000. MCV 87. The patient's sodium was 138, potassium
4.8, chloride 106, bicarbonate 119, BUN 94, creatinine 2.3,
glucose 91, anion gap 13, phosphorus 5.4, magnesium 1.9, INR
1.2, troponin 1.6, PTT 29.8, PT 13.6. The differential
revealed neutrophils 94.8, lymphocytes 2.6. TIBC 104,
ferritin 896, TRF 80, TSH 0.9, vancomycin level 10.4. Urine
sodium 15, BUN and creatinine 101. The urine albumin was 49.
The urine osms were 81. Blood cultures were positive, two
out of two bottles, for Staphylococcus aureus.
On [**2142-5-9**], foot cultures were positive for
coagulase-positive Staphylococcus.
Chest x-ray showed low lung volumes.
The EKG showed a sinus rhythm with QTC of 450, [**Street Address(2) 4793**]
depressions in lead I as well as lead aVL, as well as V5
through V6.
HOSPITAL COURSE: For the patient's shock and question of
sepsis, the patient received IV boluses of normal saline, on
current antibiotics with vancomycin, day number five of
levofloxacin, as well as clindamycin. The blood cultures
were followed, transfused packed red blood cells, increased
creatinine due to likely acute renal failure from
hypovolemia. The patient had acidosis, likely secondary to
hypoperfusion. The patient was given IV fluids. As a result
of increased cardiac enzymes, the patient had a non-Q wave
MI. Therefore, aspirin was continued. The patient had an
echocardiogram performed.
For diabetes, the patient was continued on an insulin sliding
scale. The patient was followed by Podiatry Services. The
patient's dressing was changed q.d.
Infectious Disease was consulted. On [**2142-5-11**], given the
results of the recent cultures, the antibiotics were changed
to Oxacillin 2 grams q. four hours for methicillin-sensitive
Staphylococcus aureus. The patient was also changed to
Ceftazidime 2 grams q. 24 hours and Flagyl 500 mg t.i.d.
The patient also had a right subclavian central line that was
changed on [**2142-5-12**].
The Renal Service was consulted on [**2142-5-12**]. Also, on
[**2142-5-11**], the patient had a transesophageal echocardiogram
that showed aortic vegetations in the aortic valve. This was
done as a result of the recent positive blood culture. The
patient was also transfused a total of 2 units of packed red
blood cells. The echocardiogram showed multiple mobile
lobular masses suggestive of vegetation with decreased left
ventricular function, +2 MR, as well as +2 aortic
regurgitation, minimal effusions. Repeat blood cultures were
negative.
The patient was with continued acidosis and the patient was
given bicarbonate.
On [**2142-5-12**], CT Surgery was consulted to assess for the
possibility of aortic valve replacement. It was noted that
she was a poor surgical candidate due to the multiple
comorbidities and was recommended to continue medical
treatment for her diagnosed endocarditis bacteremia. The
patient will have serial blood cultures q.d.
On [**2142-5-12**], Cardiology was also consulted. Their
recommendations include continue aspirin as well as
antibiotics for endocarditis.
On [**2142-5-13**], the patient's cardiac enzymes started to be
trending down. The patient was continued on intermittent
fluid boluses, maintain systolic pressure.
For acute renal failure, it is noted to be due to prerenal
hypoperfusion. Continued to be given fluid boluses as well
as transfusions as needed. Pneumoboots cannot be fitted on
the patient due to her obesity. As a result, on [**2142-5-13**],
the patient was transfused 1 unit of packed red blood cells.
An A line was placed and taken out. Subsequent blood
cultures up to that point were negative. The patient was
continued on Oxacillin, ofloxacin, fluconazole. Vancomycin
was discontinued.
On [**2142-5-14**], the patient had a pulmonary artery
catheterization procedure done as a result of the pulmonary
artery catheterization results, Levophed and Vasopressin
were started to maintain perfusion pressures. Catheter tip
culture showed a mixed bacterial type with greater than three
colonies, likely due to contamination.
On [**2142-5-16**], the Podiatry Service had a VAC dressing that was
changed. A right upper quadrant ultrasound showed right
pleural effusions but no evidence of cholecystitis. Repeat
TEE was done on the recommendations of Cardiology. The
patient had maintained an increased white count with a value
of 32.8, up from the previous day of 26.9. A repeat
transesophageal ultrasound showed evidence of further seeding
with possible aortic abscess and likely a septic emboli;
therefore, requiring the increased need for pressors due to
cardiovascular status.
The patient was continued on Levophed and Vasopressin for
hemodynamic stability as well as Oxacillin. The patient was
continued on Flagyl and levofloxacin.
A family meeting was held and it was discussed the patient's
poor surgical candidate status and that the patient would be
maintained on medical management with the agreement of
family. The repeat TEE evidently showed no evidence of
abscess.
On [**2142-5-17**], the patient had lumbosacral films to
investigated for other evidence of infectious sources. The
patient had an episode of SVT to the 160s. Was gradually
worsening, not able to take p.o. overnight, obtained
increased white counts.
On [**2142-5-18**], the patient had a Swan-Ganz catheter
discontinued and a left IJ was placed due to increased
nausea. Blood cultures up to [**2142-5-18**] were negative. After
remaining acidotic up to that date in spite of maintaining
perfusion pressures which were gradually worsening requiring
higher doses of Levophed as well as Vasopressin and despite
intermittent bicarbonate boluses.
On [**2142-5-18**], a Renal consult was obtained. A right IJ
Quinton catheter was placed in preparation for hemodialysis
in the future. Shortly thereafter, the patient had EKG
changes manifesting as supraventricular tachycardia with
question of A flutter. Later that day, at 3:00 p.m., the
patient had cardiac arrest due to pulseless electrical
activity. The patient was noted to have persistent
supraventricular tachycardia that started around noon that
day. It worsened despite maintenance of low systolic blood
pressures in the 100s despite Levophed and pressors, vagal
maneuver. An arrest was then called. The patient was given
1 mg of epinephrine times two, as well as sodium bicarbonate
boluses, and Atropine boluses. The patient was also given
calcium chloride boluses as well as IV fluids.
Defibrillation was ultimately performed for V tach multiple
times without success. The patient also had chest
compressions performed without success.
After 20 minutes of resuscitation efforts that were
unsuccessful, the patient expired and was pronounced. The
patient was pronounced at 3:32 p.m. after 20 minutes of
unsuccessful resuscitation. The patient was noted to be
asystolic with no blood pressures and no pulse. The pupils
were fixed and dilated. Eight minutes after 3:32 p.m., no
response to voice, no tactile stimuli such as sternal rub.
No heart sounds were noted. No breath sounds were noted.
There was no oculocephalic reflex. Request by the family was
not to have an autopsy.
DISCHARGE DIAGNOSIS:
1. Aortic valve endocarditis.
2. Diabetes.
3. Hypertension.
4. Methicillin-sensitive Staphylococcus aureus sepsis.
5. Anemia due to renal failure.
6. Morbid obesity.
7. Osteomyelitis of left calcaneous.
8. Diverticulosis.
9. Recurrent urinary tract infections.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 17322**]
MEDQUIST36
D: [**2142-6-21**] 04:06
T: [**2142-6-21**] 20:18
JOB#: [**Telephone/Fax (2) 17323**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
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[
[
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10999, 11537
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4619, 10978
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2336, 2483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,965
| 101,744
|
23026
|
Discharge summary
|
report
|
Admission Date: [**2150-12-5**] Discharge Date: [**2150-12-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Dyspnea
Reason for MICU Admission: Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 59386**] is a [**Age over 90 **] yo F with history of HTN, SVT, hx
cholangitis/E.coli bacteremia ([**2-10**]), freq UTIs, who presents
from her nursing home with acute dyspnea, hypoxia to low 80's on
RA, and fever to 102. She was recently hospitalized for LLL PNA
and D/C'd on [**12-1**] on a course of levofloxacin and flagyl. She
was changed at the nursing home from levofloxacin to cefpodoxime
for better facility acquired coverage, but has no sputum cx data
to date. She also had a urine cx sent on [**12-3**] at the NH which
is no growth to date. Per nursing home staff, she had been doing
well for the last 2 days (no O2 requirement) until 9am this
morning when she was found to be confused and lethargic and an
O2 sat was in the low 80s and did not respond to nasal cannula.
She was also found at that time to have a fever to 102.
On interviewing the patient, she denies chest pain, shortness of
breath, abdominal pain or urinary sx. She reports R ear pain.
.
In the ED, her VS were T 99.8 BP 155/96 HR 160 (sinus) O2 84% on
4L. CXR showed a worsening LLL PNA compared to [**11-30**], U/A showed
> WBC. She received CTX, azithro, and vanco as well as 2L IVFs
which brought her HR to 115. On transfer she was satting 98% on
NRB. After discussions w/ family members - she remains DNR/DNI -
plan for abx, supplemental O2, no pressors, no line, and if
worsens or in increased distress plan to switch focus to
comfort.
.
ROS: Other than above, pt unable to provide further hx.
.
Past Medical History:
--History of SVT
--hyperthyroidism
--htn
--b12 deficiency
--h/o cholangitis s/p ERCP
--Macular degeneration
--s/p TAH BSO
--s/p nephrectomy
--s/p appendectomy
--s/p hip hemiarthroplasty
Social History:
Pt lives at [**Hospital1 **] at [**Location (un) 55**]. Denies tobacco, etoh.
Reportedly a retired math teacher (7th and 8th). Played the
organ in church for years. Originally from upstate
[**State 5887**], married in [**2070**] and moved to [**Location (un) 86**] at that time.
Widowed since [**2126**]. She is a non-smoker, no EtOH, no illicit
drugs.
Son = HCP = [**Name (NI) **] [**Name (NI) 59386**] [**Telephone/Fax (1) 59387**]. Daughter ([**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 59388**] -[**Telephone/Fax (1) 59389**]) lives in [**Location **] and is ill with COPD
and home oxygen. Patient has close friend who identifies
herself as her "daughter" though admits that she is not related,
her name is [**Name (NI) 32400**] [**Name (NI) 7756**] [**Telephone/Fax (1) 59390**]. Son [**Name (NI) **] gives
permission to speak with [**Location (un) 32400**] but says that he should be the
first contact. [**Name (NI) **] family and friend [**Name (NI) 32400**], patient normally
alert, fully oriented and coherent.
Family History:
Non-contributory.
Physical Exam:
Vitals: T: 98.0 BP: 141/71 HR: 115 RR: 35 O2Sat: 99% on NRB
GEN: Respiratory distress with use of accessory muscles
HEENT: surgical pupils b/l, MM dry, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Tachycardic, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs decreased BS at bases, L > R. No crackles, wheezes
or rhonchi.
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Awake, answers simple questions. moving all extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
Pertinent Results:
Other labs/interpretation:
Resp cx: GRAM STAIN (Final [**2150-12-7**]): >25 PMNs and <10
epithelial cells/100X field ? OROPHARYNGEAL FLORA. YEAST, SPARSE
GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH. MRSA
.
.
UA [**12-5**] >50wbc, mod bact, UCx [**12-5**] >100K yeast
UA [**12-7**] 6wbc, no bacteria, UCx [**12-7**]: >100K yeast
.
.
Imaging/results:
[**2150-12-5**] CXR: Increasing left lower lobe infiltrate and pleural
effusion is concerning for progression of pneumonia. The
remainder of the study is relatively unchanged.
.
[**2150-12-7**]
Unchanged area of worsening right basilar area of consolidation
and
stable appearance of left basilar consolidation.
Unchanged slight volume overload and bronchial wall thickening.
.
[**12-10**]: Increased right pleural effusions, bilateral basilar
consolidations unchanged. Pulm vasc congeston.
Brief Hospital Course:
[**Age over 90 **] year old female with h/o SVT, HTN, recent admission with LLL
PNA (discharged [**12-1**] on levo/flagyl), admitted from [**Hospital1 1501**] with
acute onset hypoxia/dyspnea/fevers 102, CXR with worsening LLL
PNA, which has now progressed to b/l PNA, clinical evidence of
aspirartion. Afebrile and mostly stable, but episodes of
clinical deterioration.
.
.
Pneumonia, admitted with acute hypoxic resp failure, much
improved. CXR with progressive infiltrates, LLL->now bilateral
(infection vs fluid). Acuity suggests component of aspiration
pneumonitis. Has resp and oral secretions, aspirating oral
secretions, but has trouble bringing up tracheal secretions
(weak cough) and requires deep suctioning. No fevers. White
count finally coming down. She will be treated to complete a 14
day course of vanc/zosyn.
.
Given likely aspiration risk, she had multiple swallow
evaluations, with evidence of aspiration. Based on family
discussion, there is a goal of primarily comfort for patient,
with thin liquids, despite risk of aspiration. If there is
evidence of significant coughing, further evaluation or
discussions regarding goals of care should continue with her
family.
.
.
Pleural effusions: developing over 3days, likely due to
tachycardia and fluid. Diuresis for the most part was deferred
further, given minimal oral intake.
.
.
Leukocytosis: She had a leukocytosis that worsened, likely due
to pneumonia. This had resolved by [**2150-12-12**].
.
Atrial fibrillation, with intermittent tachycardia: While in the
ICU, she had evidence of tachycardia, possibly atrial
fibrillation, which broke with IV metoprolol. She continued to
have intermittent episodes of tachycardia throughout her stay,
likely sinus tachycardia in the setting of mucous plugging and
anxiety. She was maintained on IV lopressor, and transitioned
on d/c to oral lopressor.
.
Contaminated UA: UA/UCx on admission wtih >100K yeast, foley
removed, 1 dose diflucan in MICU, but repeat UCx again >100K
yeast, though UA less WBC 50->6.
No treatment pursued.
.
.
Encephalopathy: She had evidence of intermittent confusion,
consistent with delirium, due to ICU stay, pneumonia. She
gradually improved, though remains off her baseline.
.
.
HTN: Well controlled on metoprolol
.
.
PUD. cont PPI
.
.
OA/shoulder pain: lidocaine patch, no narcotics, esp given
aspiration risk
.
.
FEN/proph: HLIV, monitor lytes, soft diet with honey thick
liquids per speech only when awake, otw NPO, strict aspiration
precautions, TEDs/SCDs, heparin [**Hospital1 **], PPI
.
.
Dispo/Code status: DNR/DNI. Goals of care defined with goal
toward comfort, based on family meeting between geriatrics
service and her family (son, daughter, daughter in law). They
would like her to return to her nursing home. A
do-not-rehospitalize order will likely need to be discussed on
return to [**Hospital1 599**].
.
[**First Name8 (NamePattern2) **] [**Known lastname 59386**] is HCP(wife [**Doctor First Name **] [**Telephone/Fax (1) 59387**], c [**Telephone/Fax (1) 59391**].
Daughter ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 59388**] - [**Telephone/Fax (1) 59389**]) lives in [**Location **]
(but is ill).
Medications on Admission:
1. Metoprolol Tartrate 12.5 mg po bid
2. Docusate Sodium 200mg po bid
3. Acetaminophen 1g q8hr
4. Prilosec 20mg po q24hr
5. Cefpodoxime 100mg po bid
6. Metronidazole 500 mg po bid
7. MVI with iron
8. Remeron 15mg po qhs
9. [**Last Name (un) 7139**]-128 5% eye gtt 4x daily to each eye
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Pneumonia, bilateral
Aspiration, chronic
Pleural effusions
Atrial fibrillatoin
Encephalopathy
Discharge Condition:
Stable. Prognosis is poor.
Discharge Instructions:
You were admitted secondary to pneumonia that is likley
secondary to aspiration. You were treated for pneumonia with
antibiotics.
.
We had extensive discussion with you and your family regarding
the risk of aspiration depending on what type of food/liquids
you
consume but you will be allowed to eat food with aspiration
precautions.
.
Your doctor will discuss future plans for rehospitalization with
your family.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] on return to [**Hospital1 599**].
|
[
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"511.9",
"427.89",
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"707.21",
"401.9",
"362.50",
"V43.64",
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"715.31",
"519.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8188, 8260
|
4657, 7850
|
306, 312
|
8398, 8428
|
3789, 4634
|
8891, 8973
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3134, 3153
|
8281, 8377
|
7876, 8165
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8452, 8868
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3168, 3770
|
224, 268
|
340, 1845
|
1867, 2055
|
2071, 3118
|
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